Resins and Sealants in Pediatric Dentistry


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Resins and Sealants in Pediatric Dentistry

  1. 1. Restorative Procedures & Sealants “10” restorative questions you’ll have when working with 10” you’ in Pediatric Dentistry pediatric dentistry… dentistry… z 1. Do I need to use a rubber dam during my restorative procedure? z 2. When does a tooth need to be sealed? z 3. Do I perform a PRR, Sealant, or Occlusal Restoration? z 4. Do I use composite or amalgam as the restorative material? z 5. When do I use a SSC? z 6. Do I need to anesthetize the tooth prior to restoring/sealing it? it? z 7. When can I use glass ionomer on primary teeth? z 8. Do I place a basing agent underneath my restorations? z 9. Should I use nitrous oxide to help get this child through the restorative restorative tx? tx? z 10. How much restorative can I do on the child today? Todd M. Parco DDS Division of Pediatric Dentistry University of Minnesota School of Dentistry Objectives (Course Website & Textbook Chapters: 16, 17,18) z Understand the indications, contraindications, Oral Health Improving for Most Americans, But Tooth Decay Among Preschool Children on the Rise and techniques for pediatric dental restorations. Trends in Oral Health Status: United States, 1988-1994 and 1999-2004. Series 11, Number 248. 104 pp. (PHS) 2007-1698. z Understand the differences between pediatric dental restorations (for the primary or mixed •Tooth decay in primary (baby) teeth of children aged 2 to 5 years increased from 24 percent to 28 percent between 1988-1994 and 1999-2004. dentition) and adult restorative dentistry. •The report noted several racial/ethnic disparities. 31% of Mexican American children aged 6 to 11 years had experienced decay in their permanent teeth, compared with 19 % of non- Hispanic white children. •There were also disparities along economic lines. Three times as many children aged 6-11 (12 percent) from families with incomes below the federal poverty line had untreated tooth decay, compared with children from families with incomes above the poverty line (4 percent). Parent: “Eh, Doc, why are you fixing my child’s child’ Pediatric Considerations in teeth, they’re just going to fall out they’ Choosing Restorative Materials anyway...right?” anyway...right?” #1 Child behavior z Pain #2 Number of decayed surfaces z Infection #3 Length of time restoration will be in place (i.e. age of child) z Space loss #4 Which tooth is in need of a restoration z Carious involvement of #5 Caries rate additional teeth #6 Probability child’s family will continue child’ z Higher chance of caries with dental care in newly erupted teeth. #7 Severity of decay z Social stigma #8 Is there a parental preference
  2. 2. Mouthprops, biteblocks routinely Dental Materials…Amalgam used in pediatric dentistry. • Safety • Patient & Dentist Comfort • Better Results Mercury Silver, Tin, Copper, Zinc Dental Amalgam Dental Amalgam z Amalgam Æ technically means an alloy of z Moisture can promote failure, but mercury with any other metal. amalgam more forgiving than composite. z After the amalgam has been completely z Dental amalgam alloy is a silver-tin alloy to silver- condensed, exposure to saliva is no longer which varying amounts of copper and harmful. small amounts of zinc have been added. z If moisture control is difficult, a zinc-free zinc- high-copper allow should be used. high- z Use a fast setting amalgam when tx kids. Dental Amalgam Dental Amalgam z Insufficient depth at the isthmus of a restoration can lead z Mercury Risks to failure, therefore, how deep should your prep be when z From the FDA and the NIH: placing a class I dental amalgam? “…except for the very small fraction of the “…except population with a true allergic reaction to mercury or other constituents of amalgam, the 1.5 to 2 mm dental amalgam restoration remains a safe and effective treatment.” treatment.”
  3. 3. Pediatric Restorative Dentistry Indications for Amalgam Restorations z Class I restorations. z What are two common burs we use in z Class II restorations in primary molars when pediatric dentistry when prepping the the preparation does not extend beyond the internal surface of a tooth? proximal line angles. z Class II restorations in permanent molars and #330 and #245 premolars. z Class V restorations in primary and permanent posterior teeth. Amalgam Restorations Ultradent Metal Matrix Bands Correct Incorrect T-band T-band Next, we have SSC’s Indications for Steel Crowns: Primary Teeth z Pulpotomy and pulpectomy. pulpectomy. z Extensive multi-surface multi- caries and/or fractures. z High caries-risk patient. caries- z Hypoplastic/hypocalcified carious teeth. z Failed alloy or resin restoration.
  4. 4. Crown Preparation Prefabricated Crowns (& crown form) Prefabricated Steel Crown z Occlusal Reduction z Proximal “Slices” for “knife-edge” margins. Slices” knife- edge” z Crown engages subgingival undercuts and snaps into place. z Usual path of insertion is lingual/palatal 1st, then buccal. z Cannot adjust occlusal surface of crown at all. Need to reduce tooth or gingival margin of crown, & seat it in slight infraocclusion. infraocclusion. Pediatric SSC’s and Composite Anterior and Posterior Steel Crowns Veneered Crowns Stainless Steel Crowns on Permanent Teeth Resin Restorations in Pediatric Dentistry z Indications z Interim restoration z Pit and Fissure Sealants until appropriate permanent can be z Composite Resin placed. z Intracoronal Restorations z Strip Crowns z Developmental defects. z Microfilled, hybrid, flowable Microfilled, z Considerations z Glass Ionomers z Bases (Type III) z Periodontal Concerns z Restoratives (Type II) z Nickel Allergies z Cements (Type I) z Esthetics z Modified Glass Ionomers/Compomers
  5. 5. Resins vs Dental Amalgams • Esthetics Resin Spectrum • Adhesiveness z Least Filler: Sealant • Dimensional change z More Filler: Flowable • Resins: > 2.0 % Composite polymerization shrinkage. • Amalgam: + 0.2% z Most Filler Content: dimensional change. Composite Resin Isolation Success with Resins = z Sealants and Composite Resins z Successful bond requires maintaining “saliva-free” tooth surfaces. saliva- free” etchant, z Rubber dam use whenever possible. primer, z If unable to successfully isolate: bonding agent z Do not place elective sealant. + z Choose material other than resin for restoration. “Raincoat” (Rubber Dam) Rubber Dam Clamps “Tooth Buttons/Tooth Rings” z Clean field/better dentistry z Patient protection z Improved behavior, time management, W3 W7 and successful appointments W8A W14 W14A
  6. 6. Do not ligate through holes for rubber dam Raincoat Sequence forceps. Instead: 1) Punch holes in raincoat (double-punch hole (double- for clamped tooth) 2) Stretch raincoat loosely over hanger (frame) 3) Attach floss to button (clamp) 4) Place button on tooth/confirm secure fit 5) Stretch raincoat on hanger over button, then other teeth 6) Adjust raincoat on hanger Total Time of These Steps in the beginning…..LOTS!! Sealant Indications Sealant Failures z Primary Molars: z Very selective (often done in the OR) z Inadequate isolation from saliva z Deep stained grooves z Inadequate light cure z Caries in other quadrants on same surfaces z Voids from air bubbles z Permanent Molars: z Deep caries-prone grooves + good isolation caries- z Buccal pits & lingual grooves z Recently erupted z Repair/replace at recall appointment if z In conjunction with composite resin possible and no other treatment restorations needed. z Incisor lingual pits & premolars: prn Sealants photographed under Sealant Technique stereomicroscopy ƒUnless decay identified (or questionable) avoid enameloplasty. ƒInclude buccal and lingual pits and grooves (use bonding agent when possible for these areas) ƒEtch beyond areas to be sealed.
  7. 7. Sealant Technique A common problem with sealant (utilizing bonding agent) retention… + Sealant Failure Indications for Composite Resins 1. Esthetics/Anterior (Posterior) 2. Conservative tooth preparation 3. Bonds to sealant 4. When inadequate mechanical retention for amalgam 5. Traditionally, used less frequently than amalgam and steel crowns for primary molars. Anterior Composite Restorations Posterior Composite Resin Restorations z Use microfilled composite for maxillary z Routinely Sealed (unless all pits/grooves facial surfaces (can use hybrid for restored). strength underneath and on z Sealant is NOT considered a separate lingual/palatal surfaces) procedure/fee. z For nursing caries/early childhood z Flowable composite used very selectively caries, may prefer strip crowns or z High Speed: #330 bur (Enamel) (Enamel) esthetically-veneered steel anterior esthetically- z Low Speed: Round burs as indicated for Speed: crowns. Caries Removal in Dentin. Dentin. z Primary incisors/canines: use dovetails.
  8. 8. Problems with Composite Restorations “Sealed Composite” and/or Preventive Resin Restoration (PRR) z Posterior z Restorative Preparation z Post-treatment sensitivity (liner, incremental filling). Post- z Recurrent decay (selection, incremental filling). z Remove only detectable caries z Proximal margin microleakage is unavoidable (Aranha, (Aranha, z Etch/Bond beyond pits and grooves Pimenta, Am J Dent 2004). Pimenta, z Anterior z Composite resin (not overfilled) z Separation from tooth (strong bevel, evaluate occlusion, patient instructions, dovetails prn, athletic mouthguard prn, z Sealant area use). z Seal over restoration and any exposed pits z Color match, color changes,staining (microfilled). (microfilled). and grooves. Glass Ionomers Powder Æ fluoro-aluminocilicate glass fluoro- Liquid Æ polyacrylic acid Glass Ionomer - Uses GI Restorative Materials •Use conditioner-10% z Liner/Cement polyacrylic acid (not z A.R.T. - Atraumatic Restorative Technique phosphoric acid etchant) z Pulp Capping GI Liners z Primary teeth nearing exfoliation •Do not use conditioner or etchant z Provisional/temporary restorations GI Cements •Cementation of crowns, bands,brackets. Glass Ionomer Glass Ionomer Properties z Fluoride release z Biocompatibility z Tooth-like thermal expansion Tooth- z Do not require absolute moisture control z Chemical bond – but weak z Low strength/durability to occlusal stresses z Porous, less esthetic than composites
  9. 9. Top “10” restorative questions you’ll have when working 10” you’ Modified Glass Ionomers & Compomers with pediatric dentistry… dentistry… •Not routinely used in our clinic. z 1. Do I need to use a rubber dam? z 2. Does a tooth need to be sealed? •At present, these products offer z 3. Do I perform a PRR, Sealant, or Occlusal Restoration? a compromise that often is z 4. Do I use composite or amalgam? inferior to using composite z 5. When do I use a SSC? and/or glass ionomer materials z 6. Do I need to anesthetize the tooth prior to restoring it? (except resin-modified GI z 7. When can I use glass ionomer on primary teeth? cement). z 8. Do I place a base underneath my restoration? z 9. Should I use nitrous oxide to help get this child through the tx? tx? z 10. How much restorative can I do on the child today? Restorative Tx Planning Example Cases: Age? - 1-18 - when will exfoliation occur? Behavior? - ability to tolerate treatment (gag reflex, anxious, limited opening, etc) opening, - special needs - pre-cooperative or can comply with directions pre- Caries Risk? - high (plaque accumulation, white spot lesions, dental hx, missed appointments, SES, hx, diet, frequency of brushing, hx of caries, etc.) What Type of Physical Restoration is Needed? - how many surfaces involved, will the prep pass the line angles, is there hypocalcified enamel present, etc.) - does the child have known allergies to any of the substances you would choose? you Has the information been communicated to the parent? - does the parent have a preference of white or silver? - has the parent been informed of your tx decisions and why you are choosing the materials you are? - is cost a factor? Is the family going to be responsible for costs above what an amalgam costs costs?