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

1. RECENT ADVANCES IN PEDIATRIC
DENTISTRY

2. Use of Silver
Diamine Flouride in
Pedodontics
1
Zirconia crowns in
Pedodontics
2
Lasers in
Pedodontics
3

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

4. • 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

5. 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

6. WHY SDF IN
PEDODONTICS?

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

8. 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

10. 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%

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

12. 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%

13. 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

14. 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

15. SDF: Technique

16. • 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.

17. SIDE EFFECTS OF SDF:
Staining and Gingival Irritation

18. Recommended
Protocol for
Potassium
Iodide(KI)-
Staining Reversal
Dispense
•Dispense appropriate amount of
silver diamine fluoride (SDF)
into disposable medicine cup (one
drop can be applied to at least
fiveteeth with moderate-size
cavities).
Apply
•Apply petroleum jelly or use rubber
dam to protect soft tissuenear
affected areas.
Dry
•Dry affected tooth surfaces as much
as possible with air syringe or with
cotton pellets.
Use
•Use a microbrush saturated with SDF
to paint directly onto the tooth
surface.
Avoid
•Avoid cavity margins or soft tissues.
Allow
•Allow to absorb for one minute,
then remove excess with cotton
pellets.
Dispense
•Dispense appropriate amount of KI
into disposable medicine cup.
Use
•Use a microbrush saturated with KI
to paint directly onto the
tooth surface, like SDF application.
Reaction products form
immediately.
Restore
•Restore areas with resin-modified
glass ionomer or composite
restoration as indicated.

19. Conclusions:
Staining on posterior teeth is more acceptable to parents than on anterior teeth.
Although most parents may perceive the staining of SDF in anterior teeth as esthetically
unacceptable, many of them will accept the treatment to avoid general anesthesia
This suggests that many parents are open to compromise esthetics in favor of a less invasive
approach when their child’s cooperation is a barrier for traditional treatment.
To identify the third of parents who find the treatment unacceptable under any circumstance,
informed consent should include pictures of the staining, especially when treating anterior teeth

20. Zirconia
Crowns In
Pedodontics

21. • 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.

22. • 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.

23. • 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.

24. 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.

25. CLINICALASPECTS
• 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.

26. 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

27. 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

28. LASERS IN
PEDODONTICS

29. • 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.

30. Soft-Tissue
Applications
of Laser

31. 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.

32. Gingival Recontouring And
Crown Lengthening
• CO2 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.

33. 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.

34. 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.
• CO2 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% H2O2 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.

35. Direct And Indirect Pulp Capping Of
Young Permanent Teeth Using Laser
• CO2 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.

36. Other Soft tissue
applications
diagnosing pulp vitality
disinfection of root canal
tooth bleaching
pediatric crown preparation

37. Hard Tissue
Applications
Of Laser

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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.

44. 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

45. THANK YOU