The Hall Technique: Food for ThoughtPresentation Transcript
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
Hall’s Clinical Trial Design Patient 1 tooth Treated with crown Contralateral tooth treated with filling Age 4-9; good quality radiographs Matched decay in similar teeth procedure details recorded procedure details recorded
Hall’s Clinical Trial Algorithm treatment appointment 1 year recall 2 year recall emergency appointments recorded emergency appointments recorded
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 61 33 2 - very mild, almost trivial 32 36 3 - mild, not significant 25 34 4 - moderate, but child coped 12 23 5 - significant and unacceptable 2 6 Total number of patients 132 132
Preferred Technique by DDS, Child and Parent Child Parent Dentist
The Pedo Natural Crown The Future? Esthetic full coverage restorations Used with a GIC and acrylic system Crown form concept has adaptable margins and reported good seal and strength Pre-op Post-op Crown Forms 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.
Shadow of a Doubt: Evidence?
Reseal all broken sealants
Caries is arrested under sealants
Visual caries diagnosis is as good as explorer or digital
Today’s Teen Dilemma: Treating Incipiencies in Permanent Teeth The advent of “Dew Mouth” and similar carbonated beverage related caries patterns challenges the pediatric dentist’s traditional skills to manage these with least invasive techniques
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
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
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 don’t know which teeth should be sealed, receive enameloplasty, or have composites placed
The type of composite (filler content) is also a clinician’s choice
The use of bases also has little evidentiary support
More Fluoride Myths ? Fluoride use in infants and pre-school aged children is controversial. Mechanisms of action and dosages continue to be debated. Initial fluoride supplement dosages were empirical. Fluoride is ubiquitous in a child’s 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? MYTHBUSTERS Trooth-busters
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?
No conclusive evidence of an association between increased caries and bottle use.
ADA EBD- nothing
An 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?
Breast milk has little fluoride.
Infant formula should be mixed with fluoride free water.
Soy based formula has little fluoride.
All infants should receive a fluoride supplement beginning shortly after birth.
Pregnant mothers should receive a fluoride supplement.
Breast milk- 0.02 ppm.
Koparal et al 2000
Fluoride in infant formula causing fluorosis- weak evidence.
Hujoel et al 2009
Soy based formula-up to 0.70ppm.
Pagliari et al 2006
Prenatal fluoride supplements have no benefits
Leverett et al 1997
Reexamine the use of fluoride supplements during the first 6 years.
Ismail and Hasson 2008
Risk period for dental fluorosis
1. Topical fluoride as a cause of dental fluorosis in children (In preparation) May CM Wong 1 , Anne-Marie Glenny 2 , Boyd WK Tsang 1 , Edward CM Lo 1 , Helen V Worthington 2 , Valeria CC Marinho 3
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 meta-analysis Bardsen A. Acta Odontol Scand. 1999; 57(5):247-56
1. Fluoride supplements, dental caries and fluorosis : a systematic review.
Ismail AI, Hasson H .
J Am Dent Assoc. 2008 Nov;139(11):1457-68.
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, Weber-Gasparoni 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
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. Duration of fluoride exposure rather than the specific period better explains the development of fluorosis .
Ribbon, Pea or smear- how much toothpaste on the brush?
Ribbon of 1000ppm F toothpaste=1g=1mg of fluoride
Children under 6 years swallow 24-60% toothpaste from their brush
Pea size amount= ¼ 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.
Brushing twice a day- one just before bed and supervised
Smear for high risk children under 2 years
Pea sized amount for children 2-5 years.
Rinsing after brushing should be kept to a minimum
Tooth brushing should began as soon as the primary teeth erupt
No evidence to support the ‘wiping’ of the infants predent alveolar ridges
Medical Advances in Pediatric Health MYTHBUSTERS Trooth-Busters
Myths About Devices “ If it’s embedded, it’s premedded” is a common misconception in dentistry. With more foreign objects being used in pediatric health care, what is the evidence for using antibiotics?
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
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
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
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?
Managing Calculus Build Up
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
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 ssc Titanium implant
Non-Invasive Heart Procedures
Stints and other devices
Ask the MD
The underlying heart disease is usually the determinant of need for IE
Pacemakers and other programmable devices are susceptible to electromagnetic radiation
Shielding and refinements in cellphones and devices reducing risk
No IE coverage needed
What About Solid Tumors?
Limb sparing rather than amputation is becoming more common in bone tumors
Consult with heme/onc MD about antibiotic coverage
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
What is a Vagal Nerve Stimulator ?
Alters blood flow in thalamus
Thalamic blood correlated with seizure thresholds
Exact mechanism of action is unknown…
Treatment-resistant clinical depression
No IE coverage needed
Central Venous Access Devices
CVADs may be used in cancer, cystic fibrosis, IDDM, bleeding disorders for TPN, blood products and sampling
Prone to infection but almost always due to skin organisms
Antibiotics are not necessary and in fact discouraged
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
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
I’m 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
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
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
Botox: Self-Mutilation Management
Botox is being tested to reduce neuropathologic chewing in cases of closed head injury, toxic coma, and other neurologic conditions
Botox offers the advantage of localized rather than systemic effects
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
Thalidomide: For Immune Disorders
Thalidomide caused an epidemic of phocomelia in Great Britain in the second half of the 20 th 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
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
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 (8 th 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
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