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  • 1. William Lieberman D.D.S., M.B.A Pediatric Dentist
  • 2. Dr. William H. Lieberman D.D.S., M.B.A. • Private pediatric practice in New Jersey • Past-President American Society of Dentistry for Children • Past Trustee, American Academy of Pediatric Dentistry • MBA, Healthcare • Coordinator Dental Continuing Education, Monmouth Medical Center • Associate Clinical Professor at New York University Brief Bio.
  • 3. Shore Pediatric Dental Group
  • 4. Hygiene Room
  • 5. Prevention Restoration Remineralization
  • 6. Prevention
  • 7. American Academy of Pediatrics American Academy of Pediatric Dentistry Recommendation: Dental home by age 1
  • 8. ANTICIPATORY GUIDANCE – What is it? It is the process of providing practical, developmentally appropriate health information about children to their parents in anticipation of significant physical, emotional and psychological milestones. -Nowak and Casamassimo 1995
  • 9. Infant Exam
  • 10. Counseling Diet & Nutrition Oral Hygiene Habits
  • 11. Airway Space • The pediatric dentist can be the first to identify airway structure issues. • Learn how to incorporate this knowledge and develop a medical/dental team approach for the developing child
  • 12. Sleep Apnea
  • 13. Brodsky Tonsil Scale
  • 14. W-Loop Dental Equilibration Appliances : eg. “W-loop”
  • 15. Periodic exam Why every 6 months?
  • 16. Remineralization
  • 17. White Spot Demineralization
  • 18. Mila
  • 19. Cumulative Fluoride Release Oxman et .al. 2008 AADR Abstract #987 0 500 1000 1500 2000 2500 3000 3500 1 7 14 28 120 180 360 days FluorideReleaseppmf/g Ketac Nano Fuji II LC Vitremer Fuji IX
  • 20. Recaldent Novamin Pro-Argin Remineralizing Agents
  • 21. NYU 3 visit protocol
  • 22. First Visit Exam Counseling Varnish
  • 23. Second Visit ITR (Interim Therapuetic Resortation) Fluoride Varnish Tooth Mousse
  • 24. Third Visit Fluoride Varnish Counsel Repair
  • 25. ITS Interim Therapeutic Strip Crowns
  • 26. Restoration
  • 27. Pulp Therapy for Primary Teeth
  • 28. Successful Pulp Therapy requires: • Correct Diagnosis • Vital • Non-vital • Restoration • Microleakage
  • 29. Characteristics of Reported Pain Provoked : thermal, chemical, mechanical • indicates dentin sensitivity, pulp in transitional stage • usually acute inflammation and reversible Spontaneous • throbbing, constant • indicates advanced pulp damage • pulp usually non-treatable • irreversible pulpitis or necrosis • often nocturnal
  • 30. Radiographic Examination Internal resorption • once internal resorption has become advanced to be seen radiographically there is usually a perforation of the root by the resorptive process Pathologic bone and root resorption • Indicative of advanced pulp degeneration. The pulp tissue may remain vital even with such advanced degenerative changes.
  • 31. Medicaments for Pulpotomy Formocresol Ferric Sulfate Mineral Trioxide Aggregate (MTA)
  • 32. Pulpectomy
  • 33. IPT Technique • Gross caries removal • Walls extended to sound tooth structure • Infected dentin removed • Affected dentin remaining • Should have 1mm sound dentin over remaining pulp • Base over remaining dentin • Final restoration • Must have good marginal integrity • Recall for evaluation
  • 34. IPT Protocol • Local anesthesia and rubber dam placement • Excavation of infected dentin • Caries detector utilized • Cavity photographed • Placement of 2.0% chlorhexidine gluconate viscous solution for 60 seconds • Placement of a resin-modified glass ionomer on the preparation floor • Final restoration placement: internal or full coverage • Final photograph • Recall 3, 6 and 12 months
  • 35. Clinical Procedure
  • 36. Radiographic findings of primary first molar post-treatment 6 months post-treatment 12 months post-treatment
  • 37. Findings: • 3 month recall 100% teeth were WNL • 6 month follow-up 93% teeth were WNL • Failure of Class II composite and one SSC restoration • 12 month recall all remaining teeth were WNL ProspectiveIPTinPrimaryMolarsusingRMGIand2% CHX:A 12monthfollow-up
  • 38. Restorative Materials Composites Flowable RMGI Giomers Crowns
  • 39. Zirconium Crowns
  • 40. Sectional Matrix
  • 41. Local Anesthesia for Patients Dr. William H. Lieberman D.D.S., M.B.A. Pediatric
  • 42. 1975-2013 Then & Now • Paper Charts • Electronic Charts
  • 43. 1975-2013 Then & Now • X-Ray Film • X-Ray Sensors
  • 44. 1975-2013 Then & Now • Amalgam Restorations • Composite (RMGI) Restorations
  • 45. 1975-2013 Then & Now • Curing Light • LED Light
  • 46. 1975-2013 Then & Now • Syringes • The Wand / STA - Single Tooth Anesthesia System Instrument
  • 47. Drug choice and Volume 4% Articaine HCL • Adult: ½ cartridge • Child: ¼ cartridge • Preferred Vasoconstrictor Concentration • 1:100,000 epinephrine 2% Lidocaine HCL • Adult: ¾ cartridge • Child: ½ cartridge • Preferred vasoconstrictor concentration • 1:100,000 epinephrine
  • 48. What do you see ?
  • 49. Prevalence of Dental Fear? Agras, et al. 1979 20%
  • 50. Technology ?1853 1904 2010 150+ years
  • 51. Computer-Controlled Local Anesthetic Delivery System “New Innovation” “C-CLAD” 1997
  • 52. 1997 – 1st Generation 2007 – 3rd Generation Computer Controlled Local Anesthetic Delivery System
  • 53. Disruptive Technology •An innovation that alters a product or service in ways the market does not expect
  • 54. Allows you to do something you can’t do any other way!
  • 55. Simple mechanical system
  • 56. Dynamic Pressure Sensing Technology - DPS™ • Monitors “Exit-Pressure” • Real-Time, continuous information • Visual and audible feedback • System control: “Exit-Pressure”
  • 57. No Feedback FPO Total Feedback
  • 58. Lesson 1 Set Up and Basic Operation
  • 59. Step - 1 FRONT • Attach Foot Control • Tighten Securely BACK • Attach Power Cord • Turn Power Switch On • Wait 5 seconds for STA to Self-calibrate
  • 60. Step - 2 ANESTHETIC CARTRIDGE • Insert cartridge into holder • Press firmly until spike punctures the diaphragm
  • 61. Step - 3 Wand Handpiece & Needle • Attach Luer-Lock needle to handpiece, if necessary • Tighten securely • Place needle and cap into holder on either side of STA
  • 62. Step - 3 Shorten length of Wand Handpiece • Remove tubing handpiece • Shorten by “breaking” the length of the handle • Mark the bevel
  • 63. Step - 4 • Insert wings of holder into top of STA • Turn counter-clockwise ¼ turn • STA activates and purges handpiece of air • Lights are activated Insertion of Cartridge Holder
  • 64. Step - 4b • Turn clockwise ¼ turn • Push cartridge out using finger slots at top of cartridge holder • Remove cartridge and continue Removal of Cartridge Holder
  • 65. • The Training Mode provides an audible explanation of the various functions of the STA • Allows one to become familiar with operating the STA • Enable Training Mode by pressing and holding the “Hold to Train” button for 4 seconds Easy Learn: Training Mode Step - 5
  • 66. Step – 6 System is Ready
  • 67. Lesson 2: Performing the STA-Intra-ligamentary Injection Learn the Injection of Your Choice Lesson 3: Performing the AMSA – (Palatal) Injection
  • 68. Lesson 2 Tools needed to perform STA-IL Injection • What you need to perform this injection: • Bonded - 30-g ½ inch STA-Wand® Handpiece • The STA drive-unit set to “STA” mode • Activate Training Mode feature (optional)
  • 69. Lesson 2 Performing STA-IL Injection • What you need to learn: • How to use Cruise-control feature • Understand how DPS® works • How to use STA aspiration to prevent back-spray of anesthetic into patients mouth
  • 70. Performing STA-Intra-ligamentary Injection
  • 71. Easy Learn: Cruise Control • What is the Cruise Control feature: • The feature allows you to deliver anesthetic solution without the need of continuously depressing the foot pedal, it’s analogous to cruise-control in your car in which you release the accelerator and continue to drive. • How do you activate: 1. Start injection by depressing pedal 2. After 3 seconds voice prompt will say “Cruise” 3. Immediately release foot off pedal to remain in cruise mode • How do you de-activate: • Tap foot-control pedal to stop Step - 1
  • 72. Easy Learn: STA-IL Insertion Site • Area effected: • Single Tooth Anesthesia • Injection site: 1. Start on distal 2. Bend needle, if necessary, to gain access 3. It is best to maintain a direct view of the needle and it’s entrance to the sulcus at all times 4. It is important for the shaft of the needle to be parallel with the surface of the root Step - 2
  • 73. You need a slight bend to the needle to allow proper access.
  • 74. NOTE:Youcannotaccessthedistalofthelowermolars properlywithoutbendingtheneedleslightly. Incorrect Correct Unbent needle Bent needle (allows proper angle and access to PDL)
  • 75. • Importanttomaintaindirectvisionofproperneedleangle andneedleentranceintothesulcuswhenusingeither approach • Distal-buccal requires needle to be bent as well Buccal Approach
  • 76. Mesial Approach Incorrect needle angle and entrance Correct • Proper angle and entrance can be achieved with bent or straight needle Incorrect
  • 77.  Objective of Insertion: 1. Needle tip to entrance of PDL  Angle of Insertion: 1. 30 to 45 degrees 2. Bend needle, if necessary 3. Direct vision of needle 4. Needle shaft parallel to root  Movement of Insertion: 1. Very SLOWLY advance needle producing Anesthetic Pathway 2. Needle is inserted like a “Periodontal Probe”, gently Easy Learn: Needle Insertion Step - 3 30º
  • 78. Easy Learn: Dynamic Pressure Sensing • What is the DPS feature: • This feature provides real-time audible and visual feedback to indicate when the needle is properly positioned when performing the STA-Intra- ligamentary (PDL) injection. • How to use: 1. In STA-Mode only 2. Start injection 3. Insert needle into “assumed” correct PDL injection location 4. Wait approximately 10-15 seconds in “assumed” correct location 5. Listen & Watch, “ascending tone” & Increase of Pressure Scale through “orange” LED zone 6. Maintaining the High “orange” or the “green” LED zone throughout confirms proper needle location Step - 4
  • 79. Easy Learn: DPS® technology Trouble Shooting: • Problem: Pressure not building: 1. Insufficient hand pressure on STA/Wand handpiece 2. Did not wait 10 -15 seconds to allow pressure to build 3. Incorrect needle position Over-Pressure Alert: 1. Excessive hand pressure on STA/Wand handpiece 2. Blocked needle tip with excessive hand pressure into PDL tissue 3. Incorrect needle position Step - 5
  • 80. AMSA Injection • A new technique that enables us to anesthetize a maxillary quadrant in the primary dentition with one injection.
  • 81. Lesson 3 Tools needed to perform AMSA - Injection • What you need to perform this injection: • 30-g ½ inch – Bonded STA-Wand® Handpiece • Cotton-applicator with wooden-handle required • The STA drive-unit set to “STA” mode
  • 82. Lesson 3 How to Perform AMSA- Injection • What you need to Learn: • How to use Cruise-control feature • How to perform Pre-Puncture Technique • How to perform Anesthetic Pathway Technique • How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth
  • 83. Easy Learn: AMSA Insertion Site • Area effected: • The AMSA can produce pulpal anesthesia from the Central Incisor to the 2nd Premolar and the associated hard and soft palatal tissues. • Injection site: 1. Imagine a line located between the 1st and 2nd Premolar 2. Mid-way along an imaginary line from the palatal suture to the free gingival margin 3. Approach this site with the hand- piece from the contra-lateral premolars  Bisect premolars  Midway between the free gingival margin and mid-palatine suture Step - 1
  • 84. Easy Learn: AMSA Insertion Site • Injection site: 1. Imagine a line located between the 1st and 2nd Premolar 2. Mid-way along an imaginary line from the palatal suture to the free gingival margin 3. Approach this site with the hand- piece from the contra-lateral premolars Step - 1
  • 85. Clinical Technique: AMSA Injection
  • 86. Lesson 4 Performing P-ASA Injection • What you need to Learn: • How to use Cruise-control feature • How to perform Pre-Puncture Technique • How to perform Anesthetic Pathway Technique • How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth
  • 87. Clinical Technique: P-ASA Injection
  • 88. Easy Learn: P-ASA Insertion Site • Area effected: • The P-ASA can produce pulpal anesthesia of the Central and Lateral Incisors and the associated hard and soft palatal tissues • Injection site: 1. Entry point is the incisive groove surrounding the incisive papilla 2. Final needle tip position is within the incisive canal Step - 1
  • 89. Easy Learn: Anesthetic Pathway • What is the Pre-Puncture technique: • The technique allows you to penetrate and advance the needle through the palatal gingiva with minimal discomfort to the patient • How to perform: 1. Place bevel against surface with cotton-applicator on-top 2. Wait 8 seconds- then rotate and penetrate surface 1 - 2 mm 3. Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle 4. Advance needle until bevel contacts surface of bone Step - 2
  • 90. Clinical Technique: P-ASA Injection
  • 91. Lesson 5 Tools needed to perform IA Block Injection • What you need to perform this injection: • Smaller Children: 30-g 1 inch – Bonded STA-Wand® Handpiece • Adolescents : 27-g 1 ¼ inch – Bonded STA-Wand® Handpiece • Normal Mode
  • 92. Lesson 5 Performing IA Block Injection • What you need to Learn: • How to change to Normal Mode • How to use Cruise-control feature • How to perform Anesthetic Pathway Technique • How to use Bi-Rotational Insertion Technique • How to use STA-aspiration • How to use 2 speed operation
  • 93. Easy Learn: Bi-rotation Insertion • Bi-rotation Insertion technique: • This technique allows you to minimize needle deflection during insertion. • How to perform: • Rotate needle in a back-n-forth fashion
  • 94. Rotational Insertion Linear Insertion Deflection X X Linear Rotational Insertion Techniques
  • 95. Easy Learn: 2-Speed Operation Step - 1 1 2 • Using “Normal” mode 2- speed operation: • You can more effectively and efficiently perform the IA Block using the 2-speeds How to use: 1. Depressing the foot control lightly allows you to start the injection using the ControFlo (slower) flow rate – Use for the first ¼ cartridge of IA Block 2. Depressing the foot control all the way down allows the second, more rapid rate to administer the remaining volume of anesthetic
  • 96. Easy Learn: Aspiration Step - 2 1 2 3 • Using Aspiration to prevent intravascular needle placement: • You can prevent needle placement into a vessel by use of aspiration How to use: • After completion of needle placement: 1. Press and then release foot-control pedal to activate aspiration, which is six beeps for the complete cycle 2. If you see blood in the needle hub, re- position needle and re-aspirate until negative observation
  • 97. Easy Learn: Anesthetic Pathway • Anesthetic Pathway technique: • This technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient. • How to perform: 1. Penetrate mucosa 2. Advancement Pace: 1- 2 mm then wait 4 seconds to allow anesthetic to proceed needle 3. Advance needle until contact against surface of bone
  • 98. Lesson 7 Tools needed to Perform Supraperiosteal/Buccal Infiltration Injection • What you need to perform this injection: • 30-g 1-inch Bonded STA-Wand® Handpiece • Normal Mode
  • 99. Lesson 7 Performing Supraperiosteal/ Buccal Infiltration Injection • What you need to Learn: • How to change to Normal Mode • How to use Cruise-control feature • How to perform Anesthetic Pathway Technique • How to use STA-aspiration • How to use 2 speed operation
  • 100. Easy Learn: Anesthetic Pathway • Anesthetic Pathway technique: • The technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient. • How to perform: 1. Penetrate mucosa 2. Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle 3. Advance needle until contact against surface of bone
  • 101. Aspiration After purging, STA defaults to Aspiration ON If not needed, Aspiration can be turned OFF, by pressing Aspirate button
  • 102. Cartridge Volume • LED lights indicate amount of anesthetic solution remaining • STA “bongs” once when ¼ cartridge is expressed, twice when ½ is expressed, and three times when ¾ is used
  • 103. Sound Volume Control To Change Audible Volume: • Press up arrow to increase volume • Press down arrow to decrease volume
  • 104. Modes of operation: STA, Normal, Turbo “Select” button change • A - STA Mode – 1 speed ControlFlo only DPS® (Dynamic Pressure Sensing) • B - Normal Mode – 2 speed ControlFlo and RapidFlo • C - Turbo Mode - 3 speed ControlFlo, RapidFlo, and TurboFlo A B C
  • 105. Foot Control and Mode Selections: • Depress Pedal Slightly • ControlFlo Speed • Used for Palatal and PDL injections exclusively • Start of all injections during the first ¼ cartridge • Depress Pedal Moderately • RapidFlo Speed • Infiltration & Mandibular Block • After first ¼ cartridge only • Depress Pedal Firmly • TurboFlo Speed • After first ½ cartridge only
  • 106. DPS® - Dynamic Pressure Sensing • Informs the Dentist of Correct Injection Site (PDL Space) with Ascending Lights and Sounds • Informs the Dentist if the Needle has Left the Correct Site • Informs the Dentist if the Needle has been Blocked • All Feedback Information in Real Time
  • 107. STA-IntraligamentaryInjection Technique: DPS - Dynamic Pressure Sensing • Hold needle steadily in place with minimal pressure for approximately 15 seconds • Ascending tones and lights will indicate the needle is in the correct injection site, the periodontal ligament space • If ascending tones and lights are not initiated after 15 seconds, move needle slightly until the correct position is attained and lights and tones are seen and heard
  • 108. THE ROLE OF CCLAD IN Pediatric dentistry
  • 109. Behavioral Management • CCLAD technology has improved the overall acceptance of the anesthetic injection in the pediatric population leading to less disruptive behavior.
  • 110. References • Lieberman, William H. Clinical Session: The Wand. Pediatric Dent. 1999;21:2 • Allen KD, Kotil D, Larzelere RE, Hutfless S, Beiraghi S. Comparison of a computerized anesthesia device with a traditional syringe in preschool children. Pediatric Dent. 2002 Jul-Aug;24(4): 315-20
  • 111. Pediatric Restorative Dentistry
  • 112. Painless & Predictable
  • 113. Bi-Lateral Restorative Dentistry Efficient
  • 114. No Soft Tissue Numbness
  • 115. STA-IL Anterior Teeth
  • 116. Bevel orientation
  • 117. Mark the Bevel
  • 118. Patient Compliance
  • 119. Lack of Disruptive Behavior
  • 120. Prevent “Dripping”
  • 121. HAPPY PATIENTS
  • 122. Cooperative Patients
  • 123. Dr. Bill’s Helpful Tips •Needle choice o 30 gauge for all o1” for older children mandibular blocks o ¾” for infiltration and blocks in younger children o ½” for STA (periodontal ligament injection)
  • 124. • Break the Wand for any injection to better “cup” the needle • Mark the bevel with a permanent marker • Bend the needle with caution, as needed, for a better angle Dr. Bill’s Helpful Tips
  • 125. Dr. Bill’s Helpful Tips • Instrument location - LED’s should be clearly visible to operator & within reach • Start instrument prior to injection to avoid startling the patient • Use cruise control- NEVER turbo w/ pediatric patient
  • 126. Dr. Bill’s Helpful Tips • Avoid dripping the anesthetic in the mouth - the bitter taste is the easiest way to lose a compliant patient • Develop a consistent pattern of injection site (distolingual is best due to anatomy if manageable)
  • 127. •Rule of 2’s for STA: o20 seconds MAXIMUM time to be in one location o2 minute window to begin procedure o20 minutes to complete treatment • Watch the videos on the website…very helpful! www.STAis4U.com Dr. Bill’s Helpful Tips
  • 128. Timeliness
  • 129. Summary  Audible & visible assurance of pulpal anesthesia  Painless- minimizes disruptive behavior  Immediate onset of anesthesia o no delay is important for a child’s short attention span o saves chair time  Multiple quadrants at the same visit  No soft tissue numbness - no risk of lip biting