describes conservative and pain free techniques in pediatric dentistry

1. Dr. Nazim Mohammed Noman
Prof. Salwa Mohammed Awad
Assist. Prof Hanaa Mah. Shaalan

2. Conservative and Pain-Free
Dental Approaches for
children
Is there an alternative to conventional cavity preparation?

3. Dental caries

4. Caries process

6. Missing
Link

7. CONVENTIONAL

11. ALTERNATIVES

12.  Atraumatic restorative technique (ART).
 Interim therapeutic restoration in the primary dentition (ITR)
 Tooth preparation using air abrasion.
 Air Polishing.
 Ozone therapy.
 Chemomechanical caries removal (CMCR).
 Tooth preparation using lasers.
 Caries infiltration.
 Hall technique.

13. Minimum (or minimal) intervention
dentistry (MI)
“a philosophy of professional care concerned with
• the first occurrence,
• earliest detection, of disease on micro(molecular) levels
• earliest possible cure
followed by minimally invasive and patient friendly treatment to
repair irreversible damage caused by such disease.”

14.  Atraumatic Restorative Treatment is a method to remove caries using
only hand instruments and fill it with glass ionomer cement, can be
applied to restorative treatment of primary teeth.
 Minimally invasive procedure
 The method is showed to obtain sufficient effect comparable to
composite resin fillings? and amalgam fillings? , without inducing fear
of children.
Ref: Amercian Academy of Pediatric Dentistry 2014

15.  Mid-1980s: Pioneered in Tanzania as part of a community-based primary oral
health program by the University of Dar es Salaam
 7th April 1994 : Official adoption of ART by WHO on “World Health Day”
 By 1996: ART was being used in 25 countries.
 2002: ART was adopted as one of examples of minimal invasive dentistry, by
FDI at the annual meeting in Vienna

16. Preserving
the tooth
structure
Reducing
infection
Avoiding
discomfort
Goals

19. Cannot be used in deep carious lesions as well as
teeth that are painful and pulp is exposed

20.  A preventive (ART sealant) component and
 A restorative (ART restoration) component.
ART consists of two components:

21. ART sealant: a) vulnerable pit and fissure;
b) HVGIC applied with ‘press-finger’
method; c) situation after removal of
finger. Excess HVGIC is pushed to the sides
and can be removed easily with an
applier-carver instrument; d) final ART
sealant after bite check (Courtesy of
Professor F. de Lima Navarro)

22. ART restoration method: a) small cavity in
dentine; b) cavity opening is widened with the
ART opener instrument. Weak enamel
crumbles; c) cavity opening is now large
enough for the small excavator to enter and
to remove soft, decomposed tissue; d)
finished ART-restoration (© J. Frencken and S.
Leal)

23. Outcomes of ART-related studies
 The mean survival percentage of fully and partially retained ART/HVGIC
sealants after 1, 2, 3, 4, 5 and 6 years are 79%, 69%, 68%, 63%, 62% and 59%
respectively
 The mean annual failure rate of single-surface and multiple-surface
ART/HVGIC restorations in primary molars over 3 years was 5% and 17%
respectively

24. Interim therapeutic restoration in the
primary dentition
 ITR is minimally invasive and includes only asymptomatic primary incisors or
molars with lesions confined to dentin with sound enamel margins, along with
a plan for future follow-up and final restoration
 May be the procedure of choice for restoration in uncooperative children,
young children, or children with special needs when definitive restorative
treatment cannot be performed
 Carious lesions ideal for ITR are mesial caries on maxillary incisors, facial
caries, cervical caries, and occlusal caries in the primary molars
 Stepwise excavation of open carious lesions is another indication for ITR
(American Academy of Pediatric Dentistry, 2014b; AAPD
 The procedure can be performed in 5 min or less without the use of local
anesthesia or a rubber dam.

26. Materials
 A high-viscosity glass ionomer is the material of choice for restoration owing
to the ease of use and physical properties.
 Glass ionomer is fluoride releasing, esthetically acceptable, tolerates some
moisture contamination, chemically bonds to the tooth, and chemically cures.
 Application with the use of preloaded capsules in a capsule applier or gun
significantly reduces working time.

27. Procedure
Slow speed with round bur to remove superficial caries

28. Spoon excavator to remove superficial caries

29. Dri-angles to retract cheek and tongue while placing glass ionomer

30. Clinician’s finger compressing glass ionomer

31. Air Abrasion
 aluminum oxide particles (27 or 50 um) are blasted against teeth under a
range of pressures (30-160 psi) with variable particle flow rates

33. Principles of Air abrasion
 Accurate diagnosis of unsound tooth structure and decay.
 Accurate removal of unsound tooth structure with minimal
destruction of sound tooth structure.
 Restorative treatment planning based on the probability of
longevity of the restorative material.

34. HOW DOES IT WORK?
 Air abrasion for restoration preparation removes tooth structure using a
stream of aluminum oxide particles generated from compressed air or bottled
carbon dioxide or nitrogen gas
 The abrasive particles strike the tooth with high velocity and remove small
amounts of tooth structure
 Efficiency of removal is relative to the hardness of the tissue or material
being removed and the operating parameters of the air abrasion device

35. Clinical uses
 Class I, II, III, IV, V cavity preparations
 Sealants and preventive restorations
 Repair of composite and porcelain especially margin of veneers
 Removal of composite and amalgam.

37. USES/APPLICATIONS
 1. Removal of superficial enamel defects
 2. for detection of pit and fissure caries by removing organic debris
 3. Air abrasion can also be used for the removal of pit and fissure surface stain on
enamel
 4. Teeth where the caries is restricted only to a small section of the tooth can
also be prepared using air abrasives for conservation of sound tooth structure
 5. Surface preparation of abfractions and abrasions – air abrasion breaks the glaze
of the highly polished surface that is not suitable for bonding
 6. Removal of existing restorations

38. Air abrasion used to remove & restore pit &
fissure caries using 27 micron-sized powder
particles.
Air abrasion used to remove old amalgam
restoration using 50 micron-sized powder
particles followed by replacement with
composite resins

39. Sand trap: This is soft plastic sphere that slip onto office suction and
have a top opening through which the air abrasive system tip is
introduced This prevents the abrasive particles from entering the
patient’s oral cavity

40. LIMITATIONS
 Is not an efficient means of removing large amalgam restorations
 Also not effective for removal of gross caries because it does not cut
substances that are soft or resilient
 the depth of penetration during cavity cannot be controlled, so it has to be
accompanied with visual inspection in regular intervals
 The splattering of the powder particles within the oral cavity and/or their
accidental ingestion is another area of concern for which use of rubber dam
isolation is a must
 Air abrasive systems also cannot be used in conjunction with magnification
devices such as loupes
 Care must be taken when working near soft tissues due to risk of laceration,
air dissection, and emboli

41. Precautions
1. Need to protect patient with glasses, rubber dam if possible.
2. Dental team needs masks and glasses.
3. Stop frequently to check the progress.
4. Start with low pressure and low power then increase as needed.
5. Hold tip 1-2 mm away from tooth at a 45 degree angle then activate.
6. Always keep tip moving.
7. Requires external suction and air evacuation for the room.
8. Use disposable mirrors.
9. Like any air stream air abrasion can cause subcutaneous emphysema.

42. Air-polishing

43. A technique utilizing a mixture of water-soluble sodium
bicarbonate and tri-calcium phosphate particles that are
applied onto the tooth surface using air pressure and
shrouded in a concentric water jet

44.  The primary goal of dental polishing, regardless of method used, is removal of
stain and/or dental plaque while preserving the enamel surface and
preserving the surface characterization of dental restorations
 Polishing used in dental procedures is accomplished by two types of wear;
abrasion or erosion
 Traditional polishing with a rubber cup and polishing paste is accomplished by
abrasion
 Air polishing is accomplished by erosion, which is the recession of surfaces, in
this case dental stain and plaque

45. INDICATIONS
Coronal polishing: To remove extrinsic stains from the enamel surfaces of teeth
Several researchers suggested the use of this technique only for removing carious
dentin at the end of cavity preparation

46. DISADVANTAGESADVANTAGES
non selected abrasive characteristic,
sound tooth structure may be affected
The water jet helps the abrasive not to
escape far from the operating field

48. Ozone therapy

49. The use of ozone will provide an alternative to
conventional drilling and filling and also it was showed that
Ozone can be used to kill bacteria present in carious lesion,
painlessly and even without anesthetic
The technique uses laser detection of caries and Ozone
treatment for less than two minutes. Ozone readily
penetrates through decayed tissue, eliminating the
ecological niche of cariogenic microorganisms as well as
priming the carious tissue for remineralization, so need
encouragement of remineralization through using other
adjuncts such as fluorides, xylitol, probiotics, etc.

50. MECHANISM OF ACTION OF OZONE
 Ozone in the gaseous or aqueous phase has been shown to be a powerful and
reliable antimicrobial agent against bacteria, fungi, protozoa and viruses
 In 2003, it was discovered that ozone can be generated in vivo in activated
neutrophils
 This discovery is of striking impact since it shows that ozone has a
physiological role, not only as a bactericide

51. A clinical ozone generator for dental applications

52. Ozone therapy and pediatric dentistry
 Application is a very quick, effective, easy and especially a painless
procedure to perform
 Not only enhance the operator efficiency but also effectively improves the
patient compliance and tolerance to the treatment procedure
 Its atraumatic, painless, non invasive nature and relative absence of
discomfort increase patient’s acceptability and compliance thus making it an
ideal treatment choice specially for pediatric patients

53. Management of pit and fissure caries
 Deep pits and fissures are difficult to clean and hence are more likely
to cause food lodgment resulting in bacterial growth
 Cleansing the fissures prior to ozone treatment is recommended
 This permits the ozone to readily access the caries
 Ozone treatment removes the smear layer leaving behind the exposed
dentin ready for application of remineralizing agents
 sealing of the clean fissures is encouraged

54. Restorative dentistry
 When applied for prolonged duration; ozone gas has a strong bactericidal
effect on microorganisms within the dentinal tubules of deep cavities,
consequently improving the clinical success of restorations
 Crown discoloration of non-vital teeth is treated after placing bleaching paste
in the pulp chamber followed by ozone exposure for 3–4 min by the virtue of
its oxidation property

56. Chemomechanical caries removal (CMCR)
Application of a chemical solution to the carious dentine
followed by gentle removal with hand instruments

57.  It has seen to be very efficient in its caries removal effectiveness while
maintaining its minimal invasive potential.
 It is based on biological principles which involves removal of only the infected
dentine while retaining the affected dentin
 A minimally invasive technique of eliminating infected dentin using specific
chemical agents and hand instruments
 It is mainly indicated to overcome the use of burs and local anesthesia, causing
less discomfort to patients and preserving healthy dentin structure
 It is of tow types; Sodium hypochlorite based agents and Enzymatic based agents

59. Caridex
 Caridex was developed by CM Habib from a formula made of N-mono-
chloroglycine and amino butyric acid and was called as GK 101 E
 It gained FDA approval in 1984
 The system involved the intermittent application of preheated N-monochloro-
DL-2-aminobutyric acid (GK-101E) to the carious lesion
 The solution was claimed to cause disruption of collagen in the carious
dentine, thus facilitating its removal
 The mechanism of softening involved chlorination of remaining partially
degraded dentinal collagen

60.  1. Expensive
 2. Large quantity required
 3. Solution had to be heated
 4. Short shelf-life
Disadvantages of caridex

61. Carisolv
 Carisolv key difference was the use of three amino acids – Lysine, leucine, and
glutamic acid – instead of the aminobutyric acid
 These aminoacids counteracted the sodium hypochlorite aggressive behavior
at the oral healthy tissues
 Despite its effectiveness, carisolv was not a blockbuster mainly because it
required:-
1. Extensive training and registration of professionals
2. Customized instruments which increased the cost of the solution

62.  Constituents of carisolv
• Syringe one: sodium hypochlorite (0.5%)
• Syringe two: three amino acids (glutamic acid, leucine, lysine)
• Gel substance: carboxymethylcellulose
• Sodium chloride / sodium hydroxide
• Saline solution coloring indicator (red)
• Available as single mix or multi mix syringes.

63. Indications of Carisolv
 preservation of tooth structure is important.
 Root / cervical caries.
 Coronal caries with cavitation.
 Caries at the margins of crowns and bridge abutments.
 Tunnel preparations.
 Where local anesthesia is contraindicated.
 Caries in dentally anxious patients, notably needle phobic's.
 Primary carious lesions in deciduous teeth.
 Atraumatic restorative technique procedures.
 Patients with special needs.

64. Procedure for using carisolv gel:
1. The gel is applied to the carious lesion with a hand instrument.
2. After 30 seconds, carious dentin is removed gently by scraping with a hand
instrument.
3. More gel is then applied and the procedure repeated until no more carious
dentin remains, a guide to this being, when the gel removed from the tooth is
clear.

65. Papain Gel
 Papain comes from the latex of the leaves and fruits of the green adult
papaya
 In 2003, a research project in Brazil led to the development of a new formula
( known commercially as papacarie ) to universalize the use of chemo-
mechanical method for caries removal and promote its use in public health
 It is basically composed of Papain, chloramines, toluidine blue, salts,
thickening vehicle, which together are responsible for the papacarie’s
bactericide, bacteriostatic and anti-inflammatory characteristics

66. Mechanism of action of papain
 Since Papain can digest only dead cells, it acts breaking the partially degraded
collagen molecules, contributing to the degradation and elimination of the fibrin
“mantle” formed by the carious process.
 Right after the degradation, oxygen is freed, bubbles appear on the surface, and
a blearing of the gel is thus noted.
 These signs demonstrate that the removal process can be started.

67.  For removal, the use of the opposite side of an excavator, like a pendulum
movement and without cutting is recommended.
 The instrument should scrap the carious tissue without promoting any kind of
stimulus or pressure.
 The main characteristics of the complete removal of infected dentinal tissue
is the vitreous aspect of the cavity which appears after using Papacarie.

68. Clinical procedure of Papain Gel
 1. Black arrow indicating proximo-cclusal
carious lesion
 2. Isolation and application of Papain Gel
 3. Caries had been removed
 4. Red arrow showing filled cavity with
composite
1 2
34

69. The effectiveness of Chemomechanical techniques in caries removal has been
proved in in-vivo and in-vitro studies
 Studies by Ericson, Banerjee and Fure showed that chemo-mechanical caries
removal was as effective as the bur in caries removal
 A study by Munshi proved its use in pediatric practice. Chaussain-Miller proved its
efficiency in general practice but concluded that the process is slow and needs to
be made more efficient
 Lumbau conducted a study of Carisolv on deep carious lesions and concluded that
Carisolv is a valid alternative to the traditional techniques, saving precious dental
tissue in indirect capping cases
 Rafique et al. conducted a clinical trial of combined use of air- abrasion/Carisolv.
The conclusion drawn from the study was that air-abrasion/Carisolv gel treatment
was a well-accepted and viable alternative to conventional local anaesthetic
injection and drill for dental patients

70. Laser therapy

72. Icon Infiltration
Completed in one, 15-minute, visit

73. To arrest the progression of non-cavitated
interproximal caries lesions by penetration
of a low viscosity resin into the porous
lesion body of enamel caries

74.  It is the first product to bridge the gap between prevention (fluoride
therapy) and caries restoration
 Indicated to treat smooth surface and proximal carious lesions up to
the first third of dentin (D-1)
 Icon can arrest the progression of early enamel lesions and remove
white spot lesions

75. Incipient caries before treatment
Cariogenic acids attack the enamel
and draw out minerals. The tooth
becomes porous
After treatment
By sealing the pore system, acids can
no longer penetrate into the lesion,
thus stopping the progression of the
caries at an early stage

76. Advantages
 remove only the infected demineralised dentin while retaining the
affected remineralisable dentin
 eliminate the noise of motor driven instruments and reduce pain
perception
 reduce the anxiety in patients, especially children
 no harm expected either on the healthy dentine or the pulp tissues due to
their Conservative and Pain-free approach
Disadvantages
ICON can not penetrate caries more than the first third of dentin

78. A systematic review and meta-analysis on the effectiveness
of sealing non-cavitated proximal caries lesions in primary
teeth concluded that the technique of sealing non-cavitated
proximal caries seems to be effective in controlling proximal
caries
A randomized split-mouth placebo-controlled clinical trial
reported that resin infiltration of proximal lesions was more
effective in preventing caries progression than non-operative
measures alone after 18 months
Ammari et al. 2014
Paris & Meyer-Lueckel 2010

79. Hall technique “Sealing in” caries
The SSC is cemented in place without any
tooth preparation or local anesthesia, and
carious tooth tissue is not removed, but
sealed into the tooth by the SSC and
cement, thus isolating it from the rest of
the mouth

80. Hall technique “Sealing in” caries
The concept
 HT recommended a simple way in managing early enamel and dentinal decay
in the primary molar using a SSC; this technique involved no LA, no rubber
dam, no drilling and took place in a child friendly
 The technique relied on sealing the carious lesion in situ cutting off its supply
of sugary substrate, thus altering the bacterial plaque of the lesion ultimately
leading to the arrest of the caries process in the tooth

82. Indications and contra-indications of the Hall technique
(adopted from Innes et al., 2009).
 Class I lesion, non-cavitated, if patient unable to accept
fissure sealant, or conventional restoration
 Class I lesion, cavitated, if patient unable to accept partial caries
removal technique, or conventional restoration
 Class II lesions, cavitated or non-cavitated
Indications
 Teeth with signs or symptoms of irreversible pulpitis, or dental sepsis
(pulpal pathosis)
 Teeth with clinical or radiographic signs of pulpal exposure, or
periradicular pathology
 Teeth with crowns so broken down with caries, they would normally
be considered as unrestorable with conventional techniques
 Patients at risk of infective endocarditis
Contraindications

87. “
”
Can the Hall technique be used
to restore all Ds and Es in one
patient?
Ghaith B, Hussein I. The Hall Technique in paediatric dentistry: a review of the literature
and an “All Hall” case report with a 24 month follow up. Stoma Edu J. 2017;4(3):208-217
“All Hall”

88. Case presentation
 A fit and healthy three-year old male child
 After clinical and radiographic examination, the patient was diagnosed as having
numerous asymptomatic carious primary molar and incisor teeth fitting with the
diagnosis of Severe Early Childhood Caries (S-ECC).
 The patient’s eight carious primary molars (55, 54, 64, 65, 75, 74, 84 & 85) were
symptom free
 No clinical and radiographic signs of pulp pathology
 Child’s initial cooperation was categorized as “pre-cooperative”.
 The treatment options for the carious primary molars were; prevention only,
conventional restorative treatment using LA, the “Hall Technique” with no LA (and
restorations of the upper primary incisors) or full mouth rehabilitation under general
anaesthesia (GA).

89. Case treatment
Assessment, radiographs, explain treatment
options, OHI, diet sheet, orthodontic separator
64 (as parents opted for HT)
Appointment 1
Diet advice, remove separator 64. Place and
cemented SSC using HT on 64 and 84 (spaced
already), place new separators on 55 and 75
Appointment 2 (one week later) 2 SSCs placed
OHI reinforced, remove separators, cement SSC
HT on 55 and 75
Appointment 3 (one week later) 2 SSCs placed
Place new separators on 65 and 85
Appointment 4 (one week later)
Remove separators and cement SSCs HT on 65
and 85
Appointment 5 (one week later) 2 SSCs placed

90. Place separators, 54 and 74
Coincidently 51 noted to be discolored, no known
history of trauma. X-ray taken. Opted to manage
this tooth conservatively although pulpectomy or
extraction of 51 not ruled out
Appointment 6 (one week later)
Reinforce OH. Placed SSCs HT on 54 and 74. Restore
Upper anterior teeth using GIC restorations as
interim restorations
Appointment 7 (One week later) 2 SSCs placed
Check occlusion. Reinforce OHI and polish upper
anterior teeth
Appointment 8 (One week later)
No complaints. Check occlusion and OHRecall 3 months

91. All Es and Ds SSCs in situ. No symptoms.
Bitewings taken. No clinical or radiographic signs
of pathology. Occlusion had settled (No open
bite). Good gingival health
Recall 6 months later
No complaints. OH excellent. Occlusion normal.
Good gingival health. Radiographs taken.
Fluoride. Consider if cooperation improves,
anterior strip crowns with composite (in
addition to pulp therapy for 51)
Recall 9, 12, 15, 18 months later
No complaints. Bitewings taken show no
pathology. 26 noted to be impacted against 65
SSC. Dissimpacted 26 by removing SCC. 26 erupted
. Replaced SSC 65
Review at 24 months

92. Pre-operative

93. Immediately post-operative

94. 9 months post-operative

95. 24 months post-operative

96. Pre-operative

97. 6 months post-op

98. 12 months post-op

99. 18 months post-op

100. 24 months post-op

101. SUMMARY
Key factors for clinical SUCCESS
Early recognition of caries and intervention which are critical
Appropriate Procedure Selection
Appropriate Patient Selection

103. Evidence Based Decision Making