Silver diammine fluoride (SDF) solution is easily applied to caries lesions that meet the eye of the dentist. However, lesions that develop on approximal surfaces of contacting posterior teeth and are detected radiographically pose a unique challenge. Croll and Berg^1,2 have suggested the use of soft dental picks dipped in 38% SDF solution to soak such caries lesions to attenuate progression of the caries infections. Since 2015, we have much bite-wing radiographic evidence that the soft dental pick SDF application method is successful in abating the progress of beginning Class II caries lesions. 

To show photographic efficacy of our method, an extracted third molar was abutted in dental stone, against a newly exfoliated, primary second molar that had a carious mesial surface.² A segment of shoelace, to simulate the gingival papilla, was placed in the “interproximal” site. We then inserted an SDF-soaked soft dental pick and left it in place for 2 minutes. The third molar was then cut away, and the caries lesion was photographed before and after several millimeters of the tooth surface was trimmed away. That way, the depth of SDF penetration could be assessed. Fluoride varnish was not used in this demonstration. This report documents a similar experimental model with other extracted teeth using different steps in the procedure.

CASE REPORT

An extracted maxillary primary first molar that had a large distal surface caries lesion (Figure 1) and a smaller mesial surface caries infection. The tooth was embedded in Mortite Weatherstrip and Caulking Cord (Thermwell Products Co, Inc) with the carious distal surface abutted firmly against a proximal surface of an extracted third molar. With a thick cloth shoelace occupying the interproximal space to simulate the gingival papilla, the SDF/fluoride varnish procedure was achieved as follows:

Figure 1. Primary molar with large distal caries lesion.

Figure 2. Examples of soft dental picks coated with silver diammine fluoride (SDF) solution.

Figure 3. Molar embedded in Mortite Caulking and abutted against the third molar. The pick was inserted, and the sluiceways were painted with more SDF.

Figure 4. After 60 seconds, fluoride varnish was applied, and the system was untouched for about 60 seconds.

Figure 5. The primary molar was tipped backward in soft caulking material.

• About 1 to 2 cm of a soft dental pick was immersed in 38% SDF in a dappen dish. The tip was observed to be covered with fluid like the ones pictured in Figure 2.
• The pick was then inserted into the “interproximal space” such that a small section of the tip extended beyond the contact space. A small applicator painted extra SDF solution all along the sluiceway to ensure ideal saturation of the caries lesion (Figure 3). The pick was moved in and out slightly several times to assist the spread of the SDF over and into the caries lesion physically and by capillary action.
• After 60 seconds, the treatment field was blanketed with 5% fluoride varnish, and the experimental model was left untouched for 3 minutes (Figure 4). (This step differs from the prior laboratory demonstration.)²
• The primary molar was then tipped back into the soft Mortite caulking base (Figure 5), removed, and photographed (Figure 6).
• Using coarse aluminum oxide discs, about 3 mm of the distal tooth surface was trimmed away (Figure 7). An occlusal view shows the amount of trimming (Figure 8).
• Figure 9 demonstrates deep black coloration of the caries lesion, indicating the amount of penetration achieved by the 38% SDF fluid.

Figure 6. An SDF-soaked caries lesion with a fluoride cover in place.

Figure 7. Fluoride varnish was rinsed away, and aluminum oxide abrasive discing is shown.

Figure 8. The mesial surface was reduced about 3 mm.

Figure 9. SDF penetration deep into the caries lesion.

Figures 10 and 11. The 5-year-old’s left primary molars were treated with SDF.

Figures 12 and 13. Left primary molars, photographed 6 months after SDF treatment.

Figure 14. Comparative bite-wing films over 29 months.

This exact procedure was completed for the 4 left primary molars in September 2020 for a 5-year-old boy, requiring no local anesthetic injections (Figures 10 to 13). Photographs of the 4 treated molars were recorded on March 23, 2021 (Figures 12 and 13). The black SDF stain was apparent in the photographs but not consequential cosmetically. Bite-wing radiographs in September 2020, March of 2021, and February 2023 revealed no obvious enlargement of the proximal radiolucencies (Figure 14). Observation of the successive bite-wing radiographs shows that the caries lesions had not progressed radiographically in 29 months. The mother reported that she had flossed her son’s teeth nightly before she brushed them at bedtime.

DISCUSSION

The findings we observed in the 7-year-old over 29 months are consistent with those observed in the senior author’s child and teen patient population since dental soft pick SDF insertion was started in 2016.^1-7 A review article examined the effect of SDF on microbial activity in caries lesions.⁸ Not only does the soft dental pick interproximal SDF insertion method work, as evidenced by radiography, but this laboratory demonstration, by physical observation, also gives evidence of the effectiveness of that treatment. It is noteworthy that successful chemical attenuation of the caries lesions in this patient occurred with only one SDF application. Frequency of subsequent applications, we believe, should be customized for each patient depending upon flossing habits and ongoing caries susceptibility.

We believe the fluoride varnish coating, after application of the SDF, not only shields the SDF from dilution by saliva, prolonging its action, but also has a usual remineralizing effect on all associated enamel surfaces. In practice, we consider it critical for the dentist and clinical staff to instruct patients and parents about the importance of daily flossing so that the interproximal acid challenge to proximal tooth surfaces is eliminated or at least minimized. How flossing is achieved also needs to be taught to older children and teens, and parents need to be shown how to floss younger children until those youngsters have the manual dexterity and understanding to do the job for themselves. That commonly occurs between 9 and 11 years of age. Vivid, large photographs of what flossing accomplishes, and what non-flossing leads to, are also quite helpful in this preventive dentistry teaching quest.

Fair criticism of our experimental model and observations of the depth of penetration of the SDF liquid could be that the extracted tooth was drier than a caries lesion in a tooth in the mouth. SDF in a wetter tooth and lesion would probably take a longer time to penetrate so deeply into tooth structure. The fluoride varnish coating protecting the SDF action perhaps affords that additional time. This question could be answered by an in vitro study with saliva or an artificial saliva-soaked extracted tooth.

REFERENCES

1. Croll TP, Berg JH. Delivery of fluoride solutions to proximal tooth surfaces. Part II: Caries interception with silver diamine fluoride. Inside Dentistry. 2017;13(9):56–8. 

2. Croll TP, Berg JH. Delivery methods of silver diammine fluoride to contacting proximal tooth surfaces and history of silver in dentistry. Compend Contin Educ Dent. 2020;41(2):84–9. 

3. Croll TP, Berg JH, Donly KJ. Silver in medicine and dentistry. Inside Dentistry. 2020;16(10):35-40. 

4. Croll TP, Berg JH, Donly KJ. SDF saturation of carious proximal tooth surfaces. Dent Today. 2021;40(3):64–5.

5. Croll TP, Berg JH. Radiographic verification of silver diammine fluoride action on proximal dental caries lesions in a teenager. Dent Econ. 2021;111(5):52–3. 

6. Croll TP, Berg JH, Christensen GJ. SDF for managing open gingival floor margins in Class II restorations. Inside Dentistry. 2021;17(5):20–4. 

7. Croll TP, Berg JH. SDF application on posterior contacting axial surfaces in orthodontic patients. Dental Economics. 2023;113(5):38–9. 

8. Zhang JS, Chen Z, Chu CH, Yu OY. Effect of silver diamine fluoride upon the microbial community of carious lesions: A scoping review. J Dent. 2023;134:104554. doi:10.1016/j.jdent.2023.104554 

ABOUT THE AUTHORS

Dr. Croll is clinic director of Cavity Busters Doylestown in Doylestown, Pa; adjunct professor of pediatric dentistry at the University of Texas Health Science Center at San Antonio (Dental School); and clinical professor of pediatric dentistry at Case Western Reserve School of Dental Medicine. He can be reached at willipus@comcast.net. 

Dr. Berg is Professor Emeritus and former Dean of the University of Washington School of Dentistry. He can be reached at execudent@msn.com.

Dr. Ferretti is the Anne Hunter Jenkins Endowed Master Clinician in Pediatric Dentistry and Orthodontics and chief of dentistry at Rainbow Babies and Children’s Hospital and professor, chair, and program director of pediatric dentistry at Case Western Reserve School of Dental Medicine. He can be reached at gerald.ferretti@case.edu

Dr. Jefferies is a guest researcher in the Department of Applied Materials Science at Uppsala University in Uppsala, Sweden. He can be reached at sjefferie@aol.com.

Disclosure: The authors report no disclosures. 

Choosing the right composite resin restorative material must be based upon our patients’ needs and the properties of the materials. Obviously, when our patients are children, it is desirable to use materials and techniques that are efficient and effective. Ultimately, the success of a restoration in a child’s mouth depends upon proper diagnosis and the ability to deliver treatment with a selection of appropriate materials and techniques. Simplicity and success go hand in hand.

NEW RESTORATIVE MATERIALS
New materials have been introduced by Tokuyama Dental America. Omnichroma Flow and Omnichroma Blocker Flow (Tokuyama Dental America) have been launched as an expansion of resin-based Omnichroma restorative materials. Omnichroma is the world’s first one-shade universal composite capable of matching every patient, from A1 to D4, utilizing Tokuyama Dental’s “Smart Chromatic Technology.” As a result, workflow is streamlined as there is no need to shade match. Also, inventory and waste are reduced, as one shade of Omnichroma matches all patients. Omnichroma Blocker Flow serves to improve shade adaptation by preventing Omnichroma from picking up the oral cavity’s darkness and by masking stains or other discolored imperfections.

The introduction of flowable materials Omnichroma Flow and Omnichroma Blocker Flow now allows for the ability to restore with the advantages of this technology and the advantages of a flowable delivery system. Traditional packable composite resins have challenges and can be difficult to handle, requiring effort to adapt to cavity preparation walls. Traditional packable composites, when used alone, risk leaving voids in restoration fillings.^3,4 Flowable composite resins, with their lower viscosities, adapt better to cavity preparations and have decreased incidence of voids when properly placed. Flowable composites are easier to handle and easier to deliver in hard-to-reach areas. In the past, flowable materials have traditionally had inconsistent compositions and, thus, variable mechanical and physical properties.⁵ First-generation flowable composite resin materials had mechanical properties that were very poor.⁶ This has left dental professionals with the misconception that all flowable composite materials are weak and inferior. However, now that paradigm must change. Tokuyama Dental has developed Omnichroma Flow and Omnichroma Blocker Flow to have all of the strength, versatility, and aesthetics that have been missing in the older flowable composites. These 2 products have enhanced aesthetic properties, high polishability, and stain resistance. Their physical-mechanical properties are also enhanced, with high flexural and compressive strength, low wear and abrasion, and low polymerization shrinkage. These materials can be placed easily and with confidence in the quality of the restoration. Omnichroma Flow and Omnichroma Blocker Flow have come to market, streamlining the delivery of dental restorations. Finally, there is a fast and simple way to restore.

Figure 1. Mesial carious lesion on tooth No. 75/K.	Figure 2. Preparation and removal of any soft, carious dentin.
Figure 3. Matrix placement using the Composi-Tight 3D Fusion Sectional Matrix System (Garrison Dental Solutions).	Figure 4. Selective-etch technique.

Evidence is now guiding us to the use of flowable composite resin alone as a material for direct restoration of both Class I and Class II fillings. The direct restoration technique with flowable composite for primary molars has been described as a simple method to provide effective tooth-colored fillings, layering the flowable composite in increments. This fill technique, when used in primary molars, showed acceptable results in small to moderate cavities.^7,8 In another clinical trial, heavily filled flowable composite resin materials have been shown to have equal success to packable composite materials.⁹ This substantiation and affirmation, as well as the evolution of improved materials, are guiding us to take advantage of this novel flowable resin material to simplify the placement of restorations in primary molars.

Guidelines for placement of direct restorations in primary dentition using flowable alone in an incremental fill should be followed to ensure success. First and foremost, there should be a proper treatment plan for your child patient and reliable and adequate anesthesia. After this, the single most important factor in success is isolation, either with a rubber dam or an isolation system: eg, DryShield or Isolite. Always be aware of the properties of the materials you are using and the inherent hydrophobicity of composite resins. Moisture contamination of a composite resin will lead to premature failure of your restoration. Next is proper clinical selection; composite resin restorations are successful in conservative-sized lesions. Care must be taken to remove all decay, leaving clean margins while not undermining the cusps or the buccal and lingual walls. If the lesion you are restoring is interproximal, care must also be taken to use a reliable sectional matrix system and, finally, to follow the manufacturer’s instructions for the restorative material you are using. Strict adherence to these principles will help to guarantee a quality result.

CASE STUDY
A 4-year-old patient with multiple caries was treatment planned for a full-coverage restoration and, in this case, would be restored with a prefabricated pediatric zirconia crown. Specifically for this case study, the focus will be upon the mesial carious lesion on teeth Nos. 75/K (Figure 1) and 74/L. The materials of choice for this case, Omnichroma Flow and Blocker Flow and a prefabricated pediatric zirconia crown (NuSmile), would fulfill both the function required and the aesthetics desired for this child and his or her parent.

The quadrant was isolated with a #27 Ivory rubber dam clamp and a black latex rubber dental dam (Sanctuary) in a slot-style isolation. Preparation was done with a #1116.8C FG single patient use NeoDiamond (Microcopy). Cavity design and preparation should be as conservative as possible while also allowing for sufficient depth of preparation to have enough bulk of material at a suitable thickness for the strength to resist the possibility of fracture. Simultaneously, care must be taken to ensure an adequate bulk of material to leave enough remaining tooth structure to maintain the integrity of the tooth. Attention must also be taken not to undermine any cusps while removing any infected dentin. The removal of any soft, carious dentin was accomplished with a large #8 slow-speed round bur (Figure 2).

The matrix of choice for this case is the Composi-Tight 3D Fusion Sectional Matrix System (Garrison Dental Solutions), and the rationale for the use of a sectional matrix system is as follows. Although, undoubtedly, interproximal contacts are improved when sectional matrices are used, the main rationale for using a matrix system with a ring is to maintain and properly isolate the gingival margin of the preparation and restoration. The placement of sectional matrices is of utmost importance for gingival margin integrity, prevention of leakage, and contamination of gingival crevicular fluids. In summary, the rationale for sectional matrix use in primary dentition is more for the adaptation of the matrix to the margins, allowing for less microleakage and greater longevity of the restoration (Figure 3).

A selective-etch technique with 35% phosphoric acid was used in this case and is the method of choice whenever possible. Using a selective-etch technique of applying phosphoric acid etch to enamel only using universal-type bonding agents enhances bond strength^10,11 (Figure 4). Self-etch adhesive systems are very popular due to their ease of application and versatility. Tokuyama Universal Bond (Tokuyama Dental America) is a self-etch adhesive ideal for use in pediatric patients. It is a 2-bottle self-cure system. One drop from each of the bottles Bond A and Bond B is mixed in a well and applied over all surfaces to be bonded. Care must be taken to ensure that bond is placed on all surfaces of both enamel and dentin, including those hard-to-reach areas—for example, the gingival box. In cases of primary dentition, an appropriately sized microbrush must be chosen in order to reach these areas. Once all surfaces are coated, a weak stream of air (5 seconds), followed by a medium stream of air (5 seconds) is directed to the tooth to evaporate the solvent. No light curing is required as Tokuyama Universal Bond is a self-cure adhesive (Figure 5). Direct restoration follows. In this case, Omnichroma Blocker Flow was placed. Omnichroma Blocker Flow can be placed in increments of up to 2 mm and light cured (Figure 6).

Figure 5. Self-etch adhesive system Tokuyama Universal Bond (Tokuyama Dental America).	Figure 6. Omnichroma Blocker Flow (Tokuyama Dental America) can be placed in increments of up to 2 mm and light cured.
Figure 7. Omnichroma Flow (Tokuyama Dental America) was also placed in increments of up to 2 mm and light cured.	Figure 8. An additional increment of Omnichroma Flow to replicate the marginal ridge.

Figure 9. Omnichroma Blocker Flow and Omnichroma Flow blend seamlessly and are completely imperceptible.

Following the placement of the blocker, the flow is placed, again in increments of up to 2 mm, and light cured (Figure 7). Since it is not possible to sculpt the flowable, I added an additional increment to replicate the marginal ridge (Figure 8). In primary dentition, detailed occlusal anatomy is not necessary for the form or function of the restoration. The final restoration, immediately postoperatively, is shown in Figure 9. Omnichroma Blocker Flow and Omnichroma Flow blend seamlessly and are completely imperceptible (Figure 9). (Note, as is evident in Figure 9, the interproximal contact will be modified once tooth No. 74/L is restored with the planned zirconia crown. This will be completed at the same appointment, but after placement of the composite restoration so as not to contaminate composite restoration placement with any excess hemorrhage created during preparation of the prefabricated pediatric zirconia crown.)

CONCLUSION
Caring for children in a dental office doesn’t need to be stressful. Choosing appropriate techniques and dental materials is necessary for both simplicity and success. Patient- and parent-centered care and the marriage of methods and materials will always lead to favorable outcomes.

References

1. Bücher K, Tautz A, Hickel R, et al. Longevity of composite restorations in patients with early childhood caries (ECC). Clin Oral Investig. 2014;18(3):775–82. doi:10.1007/s00784-013-1043-y
2. Pinto Gdos S, Oliveira LJ, Romano AR, et al. Longevity of posterior restorations in primary teeth: results from a paediatric dental clinic. J Dent. 2014;42(10):1248–54. doi:10.1016/j.jdent.2014.08.005
3. Opdam NJ, Roeters JJ, Peters TC, et al. Cavity wall adaptation and voids in adhesive Class I resin composite restorations. Dent Mater. 1996;12(4):230–5. doi:10.1016/s0109-5641(96)80028-5
4. Opdam NJ, Roeters JJ, Joosten M, et al. Porosities and voids in Class I restorations placed by six operators using a packable or syringable composite. Dent Mater. 2002;18(1):58-63. doi:10.1016/s0109-5641(01)00020-3
5. Baroudi K, Rodrigues JC. Flowable resin composites: a systematic review and clinical considerations. J Clin Diagn Res. 2015;9(6):ZE18-24. doi:10.7860/JCDR/2015/12294.6129
6. Bayne SC, Thompson JY, Swift EJ Jr, et al. A characterization of first-generation flowable composites. J Am Dent Assoc. 1998;129(5):567–77. doi:10.14219/jada.archive.1998.0274.
7. Bücher K, Metz I, Pitchika V, et al. Flowable composite as a direct restoration technique for primary molars. Eur J Paediatr Dent. 2017;18(3):243-246. doi:10.23804/ejpd.2017.18.03.13
8. Attar N, Turgut MD, Güngör HC. The effect of flowable resin composites as gingival increments on the microleakage of posterior resin composites. Oper Dent. 2004;29(2):162–7. https://pubmed.ncbi.nlm.nih.gov/15088727/
9. Rocha Gomes Torres C, Rêgo HM, Perote LC, et al. A split-mouth randomized clinical trial of conventional and heavy flowable composites in class II restorations. J Dent. 2014;42(7):793–9. doi:10.1016/j.jdent.2014.04.009
10. Rosa WL, Piva E, Silva AF. Bond strength of universal adhesives: A systematic review and meta-analysis. J Dent. 2015;43(7):765–76. doi:10.1016/j.jdent.2015.04.003
11. Lenzi TL, Guglielmi Cde A, Umakoshi CB, et al. One-step self-etch adhesive bonding to pre-etched primary and permanent enamel. J Dent Child (Chic). 2013;80(2):57-61.

Dr. Cohn is a general dentist, devoted solely to the practice of dentistry for children. She maintains a private practice at Kids Sleep Dentistry Winnipeg and Western Surgery Centre in Winnipeg, Man, Canada. She is proud to be a member of the American Academy of Pediatric Dentistry Speakers Bureau and the Pierre Fauchard Academy and a co-founder of the Women’s Dental Network. Dr. Cohn has been named as one of Dentistry Today’s Leaders in Continuing Education multiple years in a row. She has published several articles and conducted webinars. She enjoys lecturing on all aspects of children’s dentistry for the general practitioner, both nationally and internationally. She can be reached at drcohn@shaw.ca.

Disclosure: Dr. Cohn has received an educational grant from Tokuyama Dental America.

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The best type of tooth protection is a vacuum-formed mouthguard, custom made on a stone model of the maxillary arch. Pressure-laminated mouthguards provide an excellent fit and give particularly good protection.^16-19 Using a slightly modified method, vacuum-formed mouthguards can even be made for patients in fixed orthodontic appliances.²⁰ Some dentists, or their office auxiliaries, fabricate vacuum-formed mouthguards in their in-office labs. Others rely on commercial laboratories to make sports mouthguards using stone models, done by order of the clinicians via prescriptions.

When instructions are followed meticulously, the boil-and-bite (store-bought) mouthguards can also protect young athletes from sports-related dental injuries.⁵ These are often used when the expense of a vacuum-formed mouthguard made by the dentist or dental laboratory is prohibitive to the parent/guardian, or when a mouthguard is needed that can be rapidly generated in the family kitchen. However, the ability of parents and young athletes to fabricate boil-and-bite mouthguards varies greatly.

In some instances, a vacuum-formed mouthguard, or even a boil-and-bite mouth-formed device, may not be available. This can be due to expense or practicality. A custom mouthguard may be the most ideal, but for a child who is rapidly growing, and/or experiencing ever-changing tooth positions due to ongoing orthodontic treatment, a custom-formed device will usually not fit for an extended time period. Children and teens also frequently chew up their mouthguards during use, or lose them on the field or elsewhere. Continual replacements of these custom guards can be expensive and inconvenient for the parents.

What can be used if a coach of a children’s field hockey, soccer, baseball, or basketball team has a number of players show up with no mouthguards, and the wise decision to use tooth protectors is also a mandatory one? What tooth protector is available when a child goes skateboarding, plays in a neighborhood basketball court, or in a touch football game, or has just been fitted with full-bonded orthodontic hardware which will be moving teeth such that custom-fitted mouthguards will not fit soon after?^21,22 And what kind of mouthguard can a dentist give to a patient who just had injured teeth splinted into place, but insists on returning to the playing field?

In cases such as these, a tooth protector is needed that meets the following conditions:

• Is instantly available from the package to the mouth
• Can fit almost all children and teens because it adapts to small (6-year-old) and larger mouths (teenagers), including those with fixed orthodontic appliances, including palatal expanders
• Is comfortable and does not elicit gagging, and accommodates air exchange
• Can be sufficiently stable when the athlete occludes on the bite plane
• Is made of a soft, resilient material, approved for intraoral use, that can absorb impact and deflect traumatic forces directed at the teeth
• Protects both maxillary and mandibular teeth
• Can be attached to a helmet, if desired, by placing a lace through a breathing vent
• Can prevent crunching of the mandibular teeth against maxillary teeth in the case of a chin blow
• Is sanitary and inexpensive so periodic replacement is affordable and practical
• Even though comfortable to soft tissues, it has a bulk that is so large, that there is extremely low risk of swallowing or aspiration of the device.

Figure 2. ToothShield (PRACTICON) tooth protector and impact deflector.	Figure 3. ToothShield in place in the mouth of a 13-year-old who was being treated with bonded orthodontic appliances.

TOOTHSHIELD
ToothShield is marketed by PRACTICON as a patented tooth protector and impact deflector (Figure 2). It is manufactured (in the United States) from a thermoplastic elastomer; the same type that is used for pacifiers and nipples for baby bottles. The design includes posterior compression pads that compress the device inward, against the buccal surfaces of the posterior teeth, or attached orthodontic hardware (Figures 2 to 4). Inward compression accommodates smaller mouths, facilitated by v-shaped notches in the horizontal bite plane (Figure 2). Likewise, the notches allow for expansion, so the ToothShield spreads outward to fit larger arches. The internal aspects of the lips help stabilize the tooth protector in the anterior region, and a tilting maxillary anterior flange adapts to the labial vestibule by maxillary lip compression (Figures 3 and 5). The flange can be reduced in height with scissors, if it impinges the depth of the anterior vestibule in smaller mouths (Figure 6). In addition, a tether can be inserted for helmet attachment, if needed (Figure 7).

Informal questioning of children and teens using ToothShield have elicited only one complaint: as with any non-custom mouthguard, it can be awkward to speak with the device in place. However, the tongue and mandibular lip can stablize the ToothShield with the mouth slightly opened in order to accommodate shouting to a teammate or conversing on the field of play, as needed.

Figure 4. Posterior compression pads stabilize the device.	Figure 5. ToothShield in cross section. Horizontal bite plane protects against chin blow, and tilting flange protects and stabilizes the unit.
Figure 6. To accommodate smaller mouths, one level can be cut from maxillary flange.	Figure 7. A lace tether can be inserted to attach to a helmet.

CLOSING COMMENTS
Custom-fitted mouthguards are undoubtedly the optimal way to protect teeth from traumatic impact during sports activities. However, such mouthguards are not always available or affordable. ToothShields are adaptable to most children and teens, even to those wearing fixed orthodontic appliances, and can work as an acceptable alternative, when needed.

References

1. Cathcart JF. Mouth protectors for contact sports. Dent Dig. 1951;57:346-348.
2. Watts G, Woolard A, Singer CE. Functional mouth protectors for contact sports. J Am Dent Assoc. 1954;49:7-11.
3. Merchant HW, Warren RW. Mouth protection in contact sports. Med Bull US Army Eur. 1955;12:53-55.
4. Castaldi CR. Mouth guards in contact sports. J Conn State Dent Assoc. 1974;48:233-241.
5. Castaldi CR. Sports medicine: The protective mouth guard. In: Castaldi CR, Brass GA. Dentistry for the Adolescent. Philadelphia, PA: WB Saunders; 1980:545-554, chapter 23.
6. Castaldi CR. Sports-related oral and facial injuries in the young athlete: a new challenge for the pediatric dentist. Pediatr Dent. 1986;8:311-316.
7. Castaldi CR. Sports dentistry. ASDC J Dent Child. 1989;56:236.
8. Padilla R, Balikov S. Sports dentistry: coming of age in the ’90s. J Calif Dent Assoc. 1993;21:27-37.
9. Padilla R, Dorney B, Balikov S. Prevention of oral injuries. J Calif Dent Assoc. 1996;24:30-36.
10. Ranalli DN. Prevention of sports-related traumatic dental injuries. Dent Clin North Am. 2000;44:35-51, v-vi.
11. Walker J, Jakobsen J, Brown S. Attitudes concerning mouthguard use in 7- to 8-year-old children. ASDC J Dent Child. 2002;69:207-211,126.
12. ADA Council on Access, Prevention and Inter­professional Relations; ADA Council on Scientific Affairs. Using mouthguards to reduce the incidence and severity of sports-related oral injuries. J Am Dent Assoc. 2006;137:1712-1720.
13. Chi HH. Properly fitted custom-made mouthguards. Compend Contin Educ Dent. 2007;28:36-40.
14. Knapik JJ, Marshall SW, Lee RB, et al. Mouthguards in sport activities: history, physical properties and injury prevention effectiveness. Sports Med. 2007;37:117-144.
15. American Academy on Pediatric Dentistry Clinical Affairs Committee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Policy on prevention of sports-related orofacial injuries. Pediatr Dent. 2008-2009;30(suppl 7):58-60.
16. Padilla RR, Lee TK. Pressure-laminated athletic mouth guards: a step-by-step process. J Calif Dent Assoc. 1999;27:200-209.
17. Ranalli DN, Demas PN. Orofacial injuries from sport: preventive measures for sports medicine. Sports Med. 2002;32:409-418.
18. Padilla RR. A technique for fabricating modern athletic mouthguards. J Calif Dent Assoc. 2005;33:399-408.
19. Padilla R, Christensen GJ. Customized mouthguards for any sport [DVD]. pccdental.com/products/product/customized-mouthguards-for-any-sport.php. Accessed October 24, 2016.
20. Croll TP, Castaldi CR. Custom sports mouthguard modified for orthodontic patients and children in the transitional dentition. Pediatr Dent. 2004;26:417-420.
21. Salam S, Caldwell S. Mouthguards and orthodontic patients. J Orthod. 2008;35:270-275.
22. Keim RG. Mouthguards and orthodontics. J Clin Orthod. 2010;44:9-10.

Dr. Croll maintains a private practice in Doylestown, Pa, specializing in pediatric dentistry. He is an affiliate professor in the department of pediatric dentistry at the University of Washington School of Dentistry in Seattle and an adjunct professor in the department of pediatric dentistry at the University of Texas Health Science Center at San Antonio. He can be reached at willipus@comcast.net.

Disclosure: Dr. Croll acknowledges financial interest in ToothShield by virtue of a patent licensing and royalty agreement with PRACTICON.

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1. Detection of caries
2. Detection of periodontal disease
3. Diagnosis of other pathological conditions
4. Traumatic injuries
5. Radiographs of disabled children and adolescents
6. Developmental and genetic conditions
7. Endodontics
8. Patient and parent education
9. Sending radiographs
10. Saving time/money
11. Offering “high-tech” dentistry for your patients.²

CASE EXAMPLES
Let’s look at some case histories to illustrate the above uses and advantages of digital radiography.

Case 1: Traumatic Injuries
Patient A is a 3-year-old male who fell onto a wooden chair and displaced his maxillary central incisors lingually. The emergency room physician referred the patient to the author, and a digital intraoral radiograph was taken that allowed the evaluation of the extent of the injury (Figures 1a to 1c). The advantage of the digital radiograph was to immediately determine if the patient had moved during the procedure. If a consultation with a pediatric dentist or oral surgeon was indicated, this radiograph could be copied onto photo quality paper and/or emailed to the consulting dentist. If this patient relocated to another dentist or was visiting his family from another locale, the radiograph could be emailed to the dentist of record.³
Patient B is a 3-year-old girl who fell against a picnic table and avulsed her mandibular right primary lateral incisor.

Figure 1a. Avulsed primary incisor.	Figure 1b. Digital radiograph of avulsed tooth.

Figure 1c. Dexis intraoral radiograph.

Case 2: Developmental Disturbances to the Dentition
A 6-year-old patient with a history of trauma to the primary incisors at age 2 years exhibited an over-retained discolored primary central incisor and an unerupted permanent central incisor. In this case, the digital radiograph provided the means to detect any possible developmental disturbances (Figures 2a and 2b).

Case 3: Coronal Fracture
This 10-year-old female had a coronal fracture which occurred during a sledding accident. The endodontist e-mailed the radiographs taken during the patient’s several months of treatment and follow-up examination and treatment to the pediatric dentist (Figures 3a and 3b).

Figure 3a. Digital radiograph showing coronal fracture.	Figure 3b. Postendodontic treatment.

Case 4: Patient and Parent Education
Due to the ability to magnify the image, the patient and parent can be shown any dental disease seen on the radiograph which helps in patient/parent education (Figures 4 a to 4e).

Figure 4a. Occlusal digital x-ray.	Figure 4c. Bite-wing digital x-ray (Gendex 770 Intraoral x-ray machine).
Figure 4b. DEXIS sensor with angled corners.	Figure 4d. Note the caries detected on this.

Figure 4e. Note enlargement of digital x-ray (DEXIS) bite-wing digital radiograph (arrow).

Case 5: Pulpal Necrosis
Ben is an 18-year-old developmentally disabled adult. Due to an injury and subsequent pulp necrosis of the maxillary right central incisor, he required endodontic treatment. Under general anesthesia in an outpatient surgical center, a root canal treatment was performed. Digital radiography was utilized to allow the necessary radiographs to be taken without the need to wait for developing x-ray film. One of the digital radiographs was taken while Ben was under general anesthesia is shown in Figure 5.

Figure 5. Note the intubation tube and the endodontic file.

ADVANTAGES OF DIGITAL RADIOGRAPHY
There are many advantages of digital radiographs. Digital radiography allows the dental team to take quality radiographs with ease and efficiency. No chemicals or waiting for x-ray film processing makes the time that the patient needs to be in the dental chair much less. This is especially important for the young or disabled patient.⁴ The size and shape of the sensor is important for the comfort for the patient. One digital x-ray company has cut the corners off of the sensor design (DEXIS) which aids in the comfort of the patient.

Quality Control and Image Enhancement
Another advantage is the quality of radiographs attainable. It is very frustrating and often embarrassing to receive poor quality radiographs from colleagues. The radiographic film was underdeveloped and the resulting poor quality is neither readable nor of archival quality. Imagine what our dental team felt about the quality of the dentistry from the dental office that sent us these x-rays. On the other hand, with the software from some digital radiography companies, the dental team can receive e-mailed radiographs and place them into patients’ digital radiographic records (Figures 6a and 6b).

Figure 6a. Underdeveloped x-ray film.	Figure 6b. Quality control with digital x-rays.

Yet another advantage of digital radiography is the ability to enhance the radiographic view by enlarging, brightness control, and improvement of the contrast. This makes the digital radiograph more diagnostic to detect fractures, caries, periodontal conditions, tumors, and cysts.⁵

Special Needs Patients
As a pediatric dentist, I have many children and disabled adult patients in my practice. One of the techniques that I utilize and teach to my residents is the use of digital radiography instead of x-ray film. The advantages are the speed of taking the radiograph and the ability to determine the quality of the radiograph immediately. I also enlist the help of the parent/guardian in the taking of the radiographs (Figures 7a and 7b).

Figure 7a. Mother of special needs child helping with digital x-ray.	Figure 7b. Special needs patient with DEXIS radiography.

General Anesthesia
One of the advantages in using digital radiography for patients that are treated while under general anesthesia is the rapidity in taking the radiograph and in the saving of time by determining immediately the quality of the radiograph. This allows the progression of treatment to be accelerated, thus preventing the prolonged time that the patient needs to be under general anesthesia (Figure 8). Also, due to the software that accompanies the digital radiograph program, the radiographs are placed into the sequence previously set up by the dentist.

Save Time and Money
With digital radiography, you will not need to purchase film mounts and take the time required to mount the processed radiographs. You will also save money on the film processor and chemicals that would have been needed to develop traditional x-ray film. The author has been able to train his dental team to take full-mouth digital radiographs in less than 10 minutes without the use of chemicals and film mounts. This saves both time and money. In more than 10 years of using the digital sensors in our multidentist practice, we have only had to replace one sensor. If you are thinking about getting a wireless sensor, you must consider the possibility of the sensor being lost or ruined by accidently leaving it in a dental gown and going through the washing machine—ouch! Some of the digital radiography companies have multiple sizes of sensors; I suggest using the “keep it simple” approach. Another concern you might have is the learning curve in switching from conventional to digital radiography. It took our team of dentists, hygienists, and assistants less than 2 hours to get used to the Rinn type holders for the sensor. There are other holders for the sensor that are even more versatile (Figure 9).⁶

Figure 8. DEXIS digital x-rays with Progeny intraoral x-ray machine used for special needs adult patient under general anesthesia.	Figure 9. DEXIS Digital Sensor and Eezee-Grip Digital Sensor Holder (DENTSPLY Rinn).

CLOSING COMMENTS
As one can see, there are many advantages to using digital radiography in your practice. Consider making the change to digital if you have not already done so. Both your patients and dental team will appreciate the effort and the investment.

References
1. van der Stelt PF. Filmless imaging: the uses of digital radiography in dental practice. J Am Dent Assoc. 2005;136:1379-1387.
2. Child PL Jr, Christensen GJ. Digital radiography: an improvement? Dent Today. 2010;29:100-102.
3. Magid KS. Digital X-ray file sharing redefines the “solo” practitioner. Dent Today. 2007;26:140, 142-143.
4. Margolis F. Digital radiography in pediatric and special care dentistry. fredmargolis.com/DigitalRadiography.pdf. Accessed August 17, 2011.
5. Christensen GJ. Why switch to digital radiography? J Am Dent Assoc. 2004;135:1437-1439.
6. Dalin J. Dispelling the myths about digital radiography. Dental Economics. 2003. dentistryiq.com/index/display/article-display/188621/ articlesdental-economics/volume-93/issue-9/features/dispelling-the-myths-about-digital-radiography.html. Accessed August 17, 2011.

Dr. Margolis received his BS and DDS from The Ohio State University and his certificate in pediatric dentistry from the University of Illinois College of Dentistry. Dr. Margolis is a clinical instructor at Loyola University’s Oral Health Center and an adjunct clinical assistant professor at the University of Illinois College of Dentistry. He has received Mastership from the Academy of Laser Dentistry and is in full-time private practice of pediatric dentistry in Buffalo Grove, Ill. Dr. Margolis has contributed articles to both lay and professional journals. He is the author of a book, Beautiful Smiles for Special People, which is a course manual for dental personnel treating the disabled patient. He is co-author of a book, Pediatric Laser Dentistry and Atlas, to be published by Quintessence in 2010. He has lectured internationally. He can be reached at kidzdr@comcast.net.

Disclosure: Dr. Margolis receives product from DEXIS for use in his office.

INDICATIONS FOR FLOWABLE COMPOSITE IN YOUNG PATIENTS
There are many indications for the use of flowable composites in young patients (Table 1). Let’s look in more detail at a few of these.

Preventive Resin Restorations

Figure 1a. Permanent molar with incipient caries. (Courtesy of Giovanni Olivi)	Figure 1b. Preventive resin restoration. (Courtesy of Giovanni Olivi)
Figure 2a. Permanent molar with caries adjacent to failed sealant. (Courtesy of Giovanni Olivi)	Figure 2b. Erbium laser preparation of molar for preventive resin res­toration. (Courtesy of Giovanni Olivi)
Figure 2c. Preventive resin restoration. (Courtesy of Giovanni Olivi)	Figure 3. Bonded orthodontic brackets.

Simonsen¹ has recommended that, for the type 2 preventive resin restorations (PRR) in which the preparation involves both the enamel and dentin, a flowable composite could be utilized to replace the carious tooth structure after excavation of the incipient caries. In a recent article by Savage, et al² it was reported that flowable composite was the most widely used restorative material for the PRR among those pediatric dentists surveyed in this study. More than 30% of the pediatric dentists always use a flowable composite or a combination of flowable composite and “packable” composite/flowable composite combination (Figures 1a and 1b).² The author has found flowable composite to also be useful when a sealant has failed and incipient caries has been detected at a recall visit (Figures 2a to 2c). The Venus Diamond Flow (Heraeus Kulzer) flowable composites offer low shrinkage and high flexural strength.

Bonding Orthodontic Brackets
Vicente and Bravo³ evaluated the shear bond strength of several flowable composites after debonding of orthodontic brackets compared to a traditional orthodontic resin. The shear bond strength was measured with a universal testing machine and the adhesive remnant after debonding was quantified utilizing image analysis. The results showed that there were no significant differences between the shear bond strengths of the various groups evaluated. The orthodontic resin left significantly more adhesive on the tooth than the 3 flowable composites tested.³ Ryou, et al⁴ in a recent study concluded: “…flowable composites with no intermediate bonding resin could be conveniently applied for orthodontic bonding” (Figure 3).

Class II and V Restorations Utilizing Flowable Composite
Flowable composites are often utilized as a liner under composite restorations. The purpose is to seal the margin, which helps prevent postoperative sensitivity and secondary caries. Sadeghi and Lynch⁵ investigated the effects of a layer of flowable composite and compomer on microleakage of composite restorations that extended apically to the cement-enamel junction. The results of the study showed that when flowable composites were used as a liner, both the packable and the nanofilled composite materials had significantly less microleakage than when flowable liners were not used. There was a significant reduction of the microleakage occurring under both types of composite materials at the gingival floors5 (Figures 4a to 6b).
Illie and Hickel⁶ investigated the mechanical properties of composites and concluded that flowable composites and compomers showed comparable results. Flowable composites only differed from microfilled composites in diametric tensile strength.

Figure 4a. Class II preparation on a primary molar.	Figure 4b. Flowable composite placed.
Figure 4c. Flowable composite restoration completed.	Figure 5a. Class II preparations of bicuspid and molars.
Figure 5b. Flowable composite as a liner.	Figure 5c. Composite placed over flowable composite.
Figure 6a. Class V preparation on bicuspid.	Figure 6b. Flowable composite restoration.

Some of the flowable composites the author uses routinely includes Venus Diamond Flow. The advantages to this particular flowable composite includes the increased strength (versus a sealant), low shrinkage stress, and high flexural strength. It also has the advantage of being an exact shade match with the Venus Diamond composite system. Other flowable composites that the author uses includes GC America’s G-aenial Flo and Universal Flo and Shofu’s Beautifil Flow Plus. The advantage to the later is the release of fluoride. Kerr’s Vertise Flow has the added benefit of being self-etching.
The effects of different light-curing units on the microleakage of flowable composite resins was studied by Yazici, et al.⁷ They found that none of the Class V restorations restored with flowable composites exhibited marginal leakage of the enamel. Also, there was no significant difference exhibited between the flowable composites tested on the dentin margins.⁷

Splinting Fractured and Mobile Teeth and Orthodontic Retainers

Figure 7. Splint bonded with a flowable composite.	Figure 8a. Fractured permanent central incisor.
Figure 8b. Flowable composite bonded fractured segment to crown.	Figure 9. Orthodontic retainer bonded with flowable composite.

Tabrizi, et al⁸ found that flowable composites provided satisfactory shear bond strength comparable to a standard orthodontic resin and therefore may be used for direct bonding of lingual retainers.8 Flowable composites may be used to splint mobile teeth utilizing orthodontic wire or nylon filament splints (Ribbond). Foek, et al⁹ studied the adhesive properties of bonded orthodontic retainers to enamel, utilizing flowable composite, with both stainless steel wire versus fiber-reinforced composites. They found that the bond strengths between the fiber-reinforced composites and the orthodontic wire when used as retainers did not differ significantly (Figures 7 to 9).⁹

Repairing Small, Direct, and Indirect Restorations

Figure 10. Occlusal restoration with Venus Bulk Flowable.

Figure 11. Radiopacity of a flowable composite material.

One of the many advantageous properties of flowable composites is their ability to repair previously placed composite restorations. Papacchini, et al10 evaluated the effect of various intermediate resin agents on composite-to-composite bond strengths. The flowable composites showed good interfacial quality to the adhesives. Also, the application of flowable composites resulted in statistically superior tensile strength (Figure 10).10 The author used Venus Diamond Flow in this instance due to the studies indicating its excellent bond strength, low shrinkage stress, and shade matching quality.

IMPORTANT PROPERTIES OF FLOWABLE COMPOSITES
Flowable composites exhibit many characteristics that make them an excellent choice for indications like the ones highlighted above (Table 2). The following properties are important when treating young patients with this class of composite resin restorative material.

Radiopacity of Flowable Composites
One of the qualities of a flowable composite that is very favorable is that of being radiopaque. Venus Diamond Flow has been shown to be one of the most radiopaque flowables on the market today. Murchison, et al¹¹ in their study, stated the following: “The level of radiopacity of the tested flowable composites was variable; those with low radiodensity should be avoided in Class II restorations, where a clear determination of recurrent caries by the examining clinician could be compromised.”¹¹ Sabbagh, et al¹² agreed with a more recent study when they concluded that flowable composites used within intracoronal restorations, clinicians should use materials with high radiopacity (Figure 11).¹²

Polishing Flowable Composites
Polishablilty of the surface of the restoration is important for aesthetic and functional purposes. The surface should be able to have a smooth lustrous surface and be able to maintain this desired characteristic. Ozel, et al¹³ studied the effect of one-step polishing systems on the surface roughness of various flowable composites. The one- or 2-step polishing systems are a good choice for the polishing of flowing composites.¹³

CONCLUSION
This article briefly described and demonstrated various indications for aesthetic restorations that can be used successfully for our child and adolescent patients. Modern aesthetic techniques and flowable composite resin materials, used properly for purposes such as those presented herein, will serve to broaden the scope of aesthetic dentistry delivered for children and teens.

References

1. Simonsen RJ. Preventive resin restorations (II). Quintessence Int Dent Dig. 1978;9:95-102.
2. Savage B, McWhorter AG, Kerins CA, et al. Preventive resin restorations: practice and billing patterns of pediatric dentists. Pediatr Dent. 2009;31:210-215.
3. Vicente A, Bravo LA. Evaluation of different flowable materials for bonding brackets. Am J Dent. 2009;22:111-114.
4. Ryou DB, Park HS, Kim KH, et al. Use of flowable composites for orthodontic bracket bonding. Angle Orthod. 2008;78:1105-1109.
5. Sadeghi M, Lynch CD. The effect of flowable materials on the microleakage of Class II composite restorations that extend apical to the cemento-enamel junction. Oper Dent. 2009;34:306-311.
6. Ilie N, Hickel R. Investigations on mechanical behaviour of dental composites. Clin Oral Investig. 2009;13:427-438.
7. Yazici AR, Celik C, Davangac B, et al. Effects of different light curing units/ modes on the microleakage of flowable composite resins. Eur J Dent. 2008;2:240-246.
8. Tabrizi S, Salemis E, Usumez S. Flowable composites for bonding orthodontic retainers. Angle Orthod. 2010;80:195-200.
9. Foek DL, Ozcan M, Krebs E, et al. Adhesive properties of bonded orthodontic retainers to enamel: stainless steel wire vs fiber-reinforced composites. J Adhes Dent. 2009;11:381-390.
10. Papacchini F, Radovic I, Magni E, et al. Flowable composites as intermediate agents without adhesive application in resin composite repair. Am J Dent. 2008;21:53-58.
11. Murchison DF, Charlton DG, Moore WS. Comparative radiopacity of flowable resin composites. Quintessence Int. 1999;30:179-184.
12. Sabbagh J, Vreven J, Leloup G. Radiopacity of resin-based materials measured in film radiographs and storage phosphor plate (Digora). Oper Dent. 2004;29:677-684.
13. Ozel E, Korkmaz Y, Attar N, et al. Effect of one-step polishing systems on surface roughness of different flowable restorative materials. Dent Mater J. 2008;27:755-764.

Dr. Margolis received his BS and DDS from Ohio State University and his certificate in pediatric dentistry from the University of Illinois College of Dentistry. Dr. Margolis is a clinical instructor at Loyola University’s Oral Health Center and an adjunct clinical assistant professor at the University of Illinois College of Dentistry. He has lectured internationally and has received Mastership from the Academy of Laser Dentistry. Dr. Margolis has contributed articles to both lay and professional journals. He is the author of a book, Beautiful Smiles for Special People, which is a course manual for dental personnel treating the disabled patient. He is co-author of a book, Pediatric Laser Dentistry and Atlas, published by Quintessence. Dr. Margolis is in full-time private practice of pediatric dentistry in Buffalo Grove, Ill. He can be reached at (847) 537-7695 or via e-mail at kidzdr@comcast.net.

Disclosure: Dr. Margolis receives honoraria and products from Biolase Technologies, Inc.

THE PROBLEM

Early childhood caries is the most prevalent chronic disease of early childhood and is a major cause of school absenteeism, according to the US Department of Health and Human Services.¹ As a matter of fact, studies show that as many as 38% of children 1 to 2 years of age and 56% of children 2 to 3 years of age develop ECC.² Within certain economically disadvantaged groups, about 80% of infants and preschoolers have been found to have ECC.³ According to the Centers for Disease Control and Prevention, more than 4 million children are affected nationwide.⁴ ECC is characterized by extensive, rapidly progressive, deep decay of the upper primary incisors and often the primary molars. These decayed teeth may become necrotic and cause alveolar abscesses to develop, leading to a cellulitis of the surrounding soft tissues. The abscesses can be painful and cause harm to underlying, developing permanent teeth. Worse yet, ECC can cause disfigurement and interfere with a child’s ability to eat.³
As a matter of fact, left untreated, ECC can lead to serious illness, infection, and pain, which in turn can impair weight gain and speech while leading to learning and eating problems. As a result, ECC can increase school absenteeism and negatively affect children’s and families’ quality of life. What’s more, some studies have shown that the bacteria can cause early damage to the blood vessels of the heart, leading to early cardiac diseases.^5-7 It could be one of the contributing factors to incidences where otherwise perfectly healthy people suffer a cardiac arrest while participating in everyday activities.
Of course, the first line of defense against ECC is prevention. Dentists should encourage parents to bring their children in for their first dental visits as soon as the first tooth erupts, which usually occurs between the ages of 6 months and a year. Infant oral health visits are recommended by age 1 and include oral hygiene instructions to the parents on how to care for their infant’s teeth.⁸ Since the bacteria that infect the child’s mouth most often come from the primary caregiver, the mother is also instructed on how to reduce harmful bacteria in her own mouth.⁹ An example of this would be the use of a xylitol-based chewing gum, as xylitol has been shown to inhibit harmful bacteria growth.¹⁰
Many adjuncts exist to help maintain good infant oral health that may only be prescribed by a pediatric dental health provider, such as MI Paste (GC America), a paste consisting of casein phosphopeptide (a milk-derived protein vehicle), and amorphous calcium phosphate.¹¹ In addition, dentists should advise parents to water down juice gradually in the baby bottle, to slowly reduce the volume of nighttime feedings, and then to increase the time between feedings, gradually eliminating the nighttime feedings altogether. Pediatric dentists should then recommend that the baby bottle be gradually replaced with feedings from a cup, with the goal of discontinuing the use of the bottle when children reach age 1.¹²

THE DILEMMA

Although prevention is important, pediatric dentists (at least until prevention efforts start to eliminate or substantially reduce the incidence of ECC) need to find ways to effectively treat their young patients who develop ECC. The problem? Families often avoid treatment for a number of reasons.
First, the idea of subjecting young children to a procedure or series of procedures where anesthesia might be required is difficult for parents to fathom.¹³ Although it is possible to treat ECC with sedation, for many reasons dentists should consider general anesthesia when treating pediatric patients with this potentially dangerous problem:

• Sedation is far less reliable and less safe than controlled general anesthesia.

• The quality of care is much better with general anesthesia because the dentist can treat the child without having to constantly adjust for the child’s movement and without having to coach and encourage the child.

• All treatment can take place in one appointment, allowing the child to receive care in a timely manner. Without general anesthesia, children are often required to come in to the dental office for multiple treatments, which may ultimately exacerbate the level of anxiety.

Second, the thought of admitting their children to the hospital for treatment makes parents even more squeamish. Forcing their young toddlers to undergo a hospital-based procedure simply doesn’t sit well with many parents who want to do everything they can to protect their children from unpleasant or traumatic experiences. In addition, some parents feel especially guilty because ECC is often caused or at least exacerbated by parents allowing their children to take a bottle to bed or to consume sugar-laden beverages.
Finally, treatment costs could discourage some parents from pursuing treatment. And, the cost of treatment doubles when patients are hospitalized, further deterring parents from pursuing this option.³
Performing full-mouth rehabilitation in the hospital setting can also pose challenges for dentists. Most troubling is the fact that it is often difficult to schedule children for dental treatment in the hospital. Most hospitals set aside certain times and days for dental procedures. As a result, dentists might have to wait months to schedule patients. The wait, of course, is bad for patients who are suffering from a condition that is getting progressively worse. The pain could become more severe, the teeth could begin to abscess, and the infection could damage the bone and permanent tooth buds underneath. It is very distressing to see cases where medical insurance or hospital-created delays force the extraction of teeth that could have been saved at an earlier time.

THE SEARCH FOR A SOLUTION

Because many of these obstacles delayed or prevented our practice from providing necessary treatment to young patients, the pediatric dentists in our group started to think about what we could do to make treatment easier for our young patients and their families.
Certainly, performing the procedures in our office would help to lessen the stress that families experience with ECC treatment procedures. The office setting, especially in pediatric practices such as ours, is very calming for patients and their families. The office is decorated to appeal to children, and we provide a number of child-friendly diversions such as video games, a saltwater fish tank, and child-friendly television programming. In addition, in the office setting we would be able to have better control over the scheduling of procedures, thereby providing more timely and effective care to our patients.
Before offering ECC treatment procedures in the office setting, however, we had to overcome one major obstacle: we needed to find a safe, effective, and financially feasible way to provide anesthesia to our young patients. So, we weighed the following options:
Gain the credentials to administer the anesthesia during the procedures. Although laws differ from state to state, dentists can become certified or licensed to provide all types of anesthesia to their patients, including general anesthesia. Although dentists who undergo these training and certification programs are likely to be qualified to administer anesthesia, doing so while performing dental procedures would be extremely difficult.
Tap the services of hospital-based anesthesiologists. While these anesthesiologists certainly have the skills and expertise necessary, we realized that they might not have the right orientation to work in an office setting. In the hospital, anesthesiologists typically only provide service during the actual operations, whereas in the office setting we would want the anesthesiologists to provide preoperative and postoperative support to patients.
Use a certified registered nurse anesthetist (CRNA) to provide anesthesiology. Although CRNAs are certainly qualified to administer anesthesia, the thought of being the only doctor in the room—and possibly the building—didn’t sit well with us from a patient safety standpoint. We worried that it would be difficult for the CRNA and dentist to handle emergencies without the many common back-up resources available in hospitals, including a bevy of other anesthesiologists and emergency medicine specialists. With this option, the supervising dentist would still have to gain the credentials to administer general anesthesia. In addition, with a CRNA, the dentist would have to supervise the entire procedure, including the anesthesia. As a result, we would be taking on more legal risk when compared to being in the office with a physician anesthesiologist.
With these options, we would also have to invest and maintain expensive anesthesiology equipment. According to Ellison C. Pierce Jr, MD, a Harvard anesthesiologist and founding president of the Anesthesia Patient Safety Foundation, to ensure safety, and thereby protect ourselves from liability, our practice would have to be equipped with “a respirator, monitoring de-vices, state-of-the-art anesthesia machine and resuscitation apparatus that is commonly found in hospitals.”³

THE WINNING CHOICE

Finally, however, we discovered Mobile Anesthesiologists, an office-based anesthesiology service based in Chicago. This option would enable us to cost-effectively and safely provide general anesthesia for our young patients. With Mobile, we have been able to bring top quality equipment and expertise into our practice without making a significant up-front investment. Now, when we schedule ECC treatments or any other procedure requiring general anesthesia, Mobile dispatches an anesthesiologist and nurse, who bring along everything needed to anesthetize and recover a patient safely. Mobile Anesthesiologists is the only AAAHC-accredited (Accreditation Association for Ambulatory Health Care) ambulatory anesthesiology practice in the Midwest, and one of only 2 nationwide. The anesthesiologists are skilled in administering all types of anesthesia including general, regional, and IV sedation. In addition, Mobile provides everything needed, including drugs, supplies, equipment, and emergency equipment. Plus, Mobile is capable of handling any emergency such as cardiac arrest, airway problems, or malignant hyperthermia.
  Using such a service has resulted in a number of benefits for our practice:
Better service and improved quality. Offering an office-based option to children who need to undergo ECC procedures makes it possible for more families to get needed treatment for their children. Instead of avoiding treatment because they don’t want to traumatize their children or because of cost concerns, parents are much more likely to pursue the treatment in an office-based setting.
In addition, because the anesthesiologists are capable of properly and safely providing anesthesia for our patients, we are able to work uninterrupted in performing treatment for ECC. As a result, we are typically able to provide all treatment during one visit, as opposed to scheduling several outpatient visits. Also, because the anesthesiologists are accustomed to working in the outpatient setting, they are tuned into patient concerns. Therefore, they work closely with our young patients and families, making them feel comfortable before and after their surgical procedures.
Reduced liability concerns. Because Mobile is an accredited practice—and carries its own liability insurance—the option enables dental groups to perform outpatient surgeries without incurring additional anesthesiology-associated liability.
Decreased start-up costs. The fact that Mobile brings its own anesthesia and emergency equipment is also an attractive economic benefit, saving our practice from having to invest in such equipment or from using substandard equipment.
Improved scheduling. No longer dependent on the availability of operating suites at hospitals, we are now able to schedule our procedures to provide treatment to patients in a timely manner. In addition, the scheduling flexibility makes it possible for the dentists in our practice to schedule procedures to meet their needs as well.

References

1. US Dept of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: http://www.surgeongeneral.gov/library/oralhealth. Accessed January 2, 2007.
2. Douglass JM, et al. Estimates of caries prevalence of toddlers 12-36 months of age. Community Dent Oral Epidemiol. In press.
3. Chisick M. Protect Your Children From Baby Bottle Tooth Decay by Seeing a Dentist Early. Aberdeen Proving Ground, Md: US Army Center for Health Promotion and Preventive Medicine; 1998.
4. Beltran-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism and enamel fluorosis—United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. Aug 26, 2005;54:1-43. Available at: http://www.cdc.gov/MMWR/preview/mmwrhtml/ss5403a1.htm. Accessed January 2, 2007.
5. Scannapieco FA, Bush RB, Paju S. Association between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol. 2003;8:38-53.
6. Ford PJ, Gemmell E, Timms P, et al. Anti-P. gingivalis response correlates with atherosclerosis. J Dent Res. 2007;86:35-40.
7. Gibson FC III, Yumoto H, Takahashi Y, et al. Innate immune signaling and Porphyromonas gingivalis- accelerated atherosclerosis. J Dent Res. 2006;85:106-121.
8. Goepferd SJ. Infant oral health: a protocol. ASDC J Dent Child. 1986;53:261-266.
9. Ramos-Gomez FJ. Clinical considerations for an infant oral health care program. Compend Contin Educ Dent. 2005;26(5 suppl 1):17-23.
10. Milgrom P, Ly KA, Roberts MC, et al. Mutans streptococci dose response to xylitol chewing gum. J Dent Res. 2006;85:177-181.
11. Hicks J, Flaitz C. Amorphous calcium phosphate-casein phosphopeptide paste: effect on enamel caries formation. Abstract 0501. Presented at: ADEA/AADR/CADR Meeting & Exhibition; March 8-11, 2006; Orlando, Fla. Available at: http://iadr.confex.com/iadr/2006Orld/techprogram/abstract_73073.htm. Accessed January 11, 2007.
12. Ersin NK, Eronat N, Cogulu D, et al. Association of maternal-child characteristics as a factor in early childhood caries and salivary bacterial counts. J Dent Child (Chic). 2006;73:105-111.
13. Savanheimo N, Vehkalahti MM, Pihakari A, et al. Reasons for and parental satisfaction with children’s dental care under general anaesthesia. Int J Paediatr Dent. 2005;15:448-454.

Dr. Cannon received his DDS from the University of Nebraska and then attended Northwestern University for his masters of pediatric dentistry. He completed his residency at Children’s Memorial Hospital and received his Diplomate status by the American Board of Pediatric Dentistry. He is a past president of the Illinois Society of Dentistry for Children, an associate professor at Northwestern University, and a member of the International Academy of Pediatric Dentistry. In addition to maintaining a large private practice in the Chicago suburbs, he is actively involved in the research program at Children’s Memorial Hospital. He also presents guest lectures at the University of Nevada School of Oral Medicine and Sao Paulista State University, UNESP, Aracatuba, Brazil. He has presented to numerous domestic and international organizations. Dr. Cannon can be reached at (847) 634-6166 or cannon.m@comcast.net.

  Prevention of space loss can be achieved with space maintainers.1 The band and loop space maintainer is associated with the least number of problems.2 Problems with other appliances hinder their use. For example, lingual arches prove to have the lowest survival rate,⁵ glass fiber-reinforced composite resins (GFRCR) are for short-term use,6 and removable appliances fail due to poor compliance. Band and loop space maintainers allow unhindered eruption of permanent teeth into proper alignment and occlusion.1
  This paper presents a new technique for impressions of bands for fixed appliances, specifically space maintainers, thereby hopefully alleviating frustration for both the dentist and patient.

BACKGROUND

Contemporary impression techniques consist of alginate and a combination of alginate and wax (green stick compound) for the fabrication of fixed appliances. Although alginate has widespread use due to its commonality and low cost, alginate impressions have several shortcomings,7 which include the following:
• difficulty establishing a proper liquid-to-powder ratio to create a consistency that flows minimally
• difficulty establishing proper water temperature to create proper consistency
• flow of material posteriorly down the patient’s airway, which can cause apprehension and/or rejection of the procedure
• suction of set material, which causes impression withdrawal to be difficult
• low tear strength
• easy distortion of the material
• less accuracy than polyvinyl siloxane impressions
• necessity to pour up impression immediately to minimize distortion
• poor ability to withdraw bands from tooth.

METHODS AND MATERIALS

TempTray (Clinician’s Choice) is a disposable aluminum quadrant tray for temporary prosthodontic impressions prior to tooth preparation. The TempTray is utilized to fabricate custom temporary restorations. Template (Clinician’s Choice) is a silicone-based material that has a working time of 30 seconds and a set time of 30 seconds. It is very thixotropic, does not slump, and has excellent dimensional stability. Clinician’s Choice has not indicated pediatric applications for TempTray or Template. The author has developed the pediatric application through clinical trials.
The technique is a modified impression technique using solely Template. For simple, unilateral, fixed space maintainers, the author suggests using a TempTray with Template. The technique will be presented in detail.

UNILATERAL SPACE MAINTAINERS

Figure 1. Pretreatment diagnostic photo.	Figure 2. Placement of separator.
Figure 3. Position of separator intraorally.	Figure 4. Position of band intraorally.

Confirm the necessity of a space maintainer by proper diagnosis. In this case, tooth No. 64 was extracted due to nonrestorability (Figure 1), and a unilateral band and loop space maintainer was treatment planned to prevent the unwanted mesial drift of teeth Nos. 65 and 26.8 A separator (Figure 2) had been placed between teeth Nos. 65 and 26 following the extraction and maintained for a few days prior to the impression (Figure 3). Before the impression was taken, the separator was removed, and a stainless steel band was fitted on tooth No. 65 (Figure 4).

Figure 5. TempTray disposable tray.	Figure 6. Placement of Template into TempTray.
Figure 7. Thirty-second intraoral impression of band and loop.	Figure 8. Impression of dentition and band.
Figure 9. Model of the impression.	Figure 10. Band and loop appliance cemented intraorally.

TempTray (Figure 5) loaded with Template (Figure 6) was utilized for the impression. The material was allowed to set for about 30 seconds and then was placed in the mouth and allowed to set for 30 seconds (Figure 7). The TempTray with Template was removed, retaining the band that had been placed on tooth No. 65 (Figure 8). The impression was disinfected and poured with standard dental stone (Figure 9). To reduce cost and time, the model was poured in our in-house lab, but the practitioner has the ability to send the impression directly to the lab.
  The model was sent to a commercial lab for the fabrication of a band and loop space maintainer from teeth Nos. 65 to 63. The fixed unilateral space maintainer was cemented with Poly-F Plus cement (DENTSPLY), completing the treatment. Figure 10 shows the band and loop appliance intraorally prior to its removal upon eruption of the permanent molars.

Discussion

The Template impression technique offers the practitioner a simple and efficient method to perform pediatric impressions. The technique offers the child-patient a quick and simple procedure that is easy to tolerate and allows the clinician to perform an accurate, efficient, and inexpensive impression for the fabrication of fixed appliances. The advantages of this approach include its extremely simple method, its fast and efficient technique, its extreme accuracy and easy retention of the band on withdrawal, no need for specialized equipment, the dimensional stability of Template, excellent patient acceptance, and inexpensive costs.

Conclusion

This author has developed the Template pediatric impression technique to address the shortcomings of traditional pediatric impression techniques. The new technique represents a fast and efficient method for the accurate impression of band-related, fixed, unilateral space maintainers. The technique can be well-tolerated by the apprehensive child-patient and facilitates the procedure for clinicians and staff.

Acknowledgment

The author would like to thank Dr. Len Boksman for his assistance with this article and recognize POW Dental Laboratories for the fabrication of the appliance.

References

1. Bijoor RR, Kohli K. Contemporary space maintenance for the pediatric patient. N Y State Dent J. 2005;71:32-35.

2. Durward CS. Space maintenance in the primary and mixed dentition. Ann R Australas Coll Dent Surg. 2000;
15:203-205.

3. Rocha MJ, Cardoso M, de Oliveira J. Avulsion of posterior primary teeth and space maintaining appliance: case report. J Clin Pediatr Dent. 2000; 25:35-39.

4. Northway WM. The not-so-harmless maxillary primary first molar extraction [published correction appears in J Am Dent Assoc. 2001;132:154]. J Am Dent Assoc. 2000;131:1711-1720.

5. Rajab LD. Clinical performance and survival of space maintainers: evaluation over a period of 5 years. ASDC J Dent Child. 2002;69:156-160.

6. Kargul B, Caglar E, Kabalay U. Glass fiber reinforced composite resin space maintainer: case reports. J Dent Child (Chic). 2003; 70:258-261.

7. Craig RG. Restorative Dental Materials. 9th ed. St Louis, Mo: Mosby-Year Book; 1993:283-383.

8. Cameron AC, Widmer RP. Handbook of Pediatric Dentistry. St Louis, Mo: Mosby-Year Book; 1997:268-271.

Dr. Kalman maintains a private practice in aesthetic and general dentistry in London, Ontario, and is an adjunct professor in the Department of Oral and Maxillofacial Surgery at the School of Dentistry, University of Western Ontario. He can be reached at (519) 672-3401 or by visiting 4seasonsdental.ca.

Tooth intrusion is defined as the displacement of a tooth farther into the alveolar bone. In a retrospective study of the etiology and pathogenesis of traumatic dental injuries, Andreason found that of 2,239 injured permanent teeth, only 3% were luxated intrusively.8  In contrast, the most common luxation injuries to the primary dentition are intrusive. With a direct blow, a primary incisor can be completely intruded. This discrepancy might be related to the relative pliability of a child’s alveolar bone as compared to adult  bone. Unless the impact forces are considerable, the posterior teeth are seldom involved because of their anatomical position and multiple roots.9 The cuspids rarely are involved because the medial pillar of the maxilla is difficult to penetrate.9 In the permanent dentition, most traumatic injuries are crown fractures.10

When tooth displacement occurs, the poorest prognosis is associated with intrusively displaced teeth. Potential complications include pulpal necrosis, pulp obliteration, root resorption, ankylosis, and loss of marginal support. For intruded teeth with closed apices, the incidence of pulpal necrosis is 100%, whereas in intruded teeth with open apices, the incidence of pulpal necrosis is 63%.11 External root resorption has been reported as a complication of intrusive injuries in 58% of teeth with immature root formation and in 70% of teeth with complete root formation.11

Andreasen and Vestergaard-Pedersen11 reported a 24% incidence of ankylosis following severe intrusion and also found that marginal bone loss occurs in as many as 31% of cases of intrusive luxation. The potentially most serious complications can occur when a tooth is displaced into another part of the body or when the tooth opens a communication from the oral cavity into an anatomical space.

This article describes a case involving traumatic tooth intrusion in a child. A central incisor was not visible in the socket and initially was presumed to have been avulsed. Later, a computed axial tomogram confirmed that a mass along the nose was the missing incisor, which was then surgically removed without complication.

CASE REPORT

An 8-year-old white male presented to Cayuga Medical Center Emergency Room (Ithaca, NY) with injuries to his face and oral structures resulting from a 15-foot fall from a tree. The initial extraoral exam revealed an apparent nasal fracture with a firm mass extruding from the left lateral piriform aperture. No ecchymosis, abrasion, or tearing of the overlining epithelium had occurred. A 3-cm laceration was present on the submental skin surface.

Intraorally, the anterior segment of the premaxilla showed injury consistent with low-velocity blunt-force trauma, including multiple fractures of the alveolus and several lacerations of the gingival tissues. The patient’s maxillary right central incisor had been avulsed from the socket and was retained only by a narrow band of gingival tissue. The maxillary left central incisor was not obviously present (Figures 1a and 1b), but the child’s guardian was unable to find this missing tooth in the area under the tree from which the child had fallen. The root of the maxillary left lateral incisor had an oblique fracture. In addition, the mandibular anterior segment was fractured “enbloc” with teeth Nos. 23 to 26, and the accompanying alveolus was lingually displaced.

Figure 2. A computed axial tomogram confirms that the suspicious mass protruding from the lateral perinasal region was the missing tooth.

Cervical spine radiographs failed to reveal the missing maxillary left central incisor, but a panoramic radiograph showed a suspicious radiopaque mass lateral to the nasal septum. Closer examination of the apparent nasal fracture suggested that the deviated mass was too firm to be cartilaginous. A computed axial tomogram confirmed that the suspicious mass protruding from the lateral perinasal region was the missing tooth (Figure 2).  

After extraction of the avulsed right central incisor and left lateral incisor, manual pressure was used to reposition the fractured segments of the maxilla, and resorbable sutures were used to close the intraoral lacerations. Next, the fractured alveolus of the mandibular arch was repositioned using carbon fiber ribbon, and the fractured alveolar segment was stabilized with light-cured composite resin. Finally, the submental laceration was closed with silk sutures. Follow-up prescriptions included the antibiotics penicillin and clindamycin, together with Lortab (UCB Pharma) as needed for pain. For removal of the intruded central incisor, the patient was referred to an oral surgeon.

Approximately 7 days later, the patient was placed under general anesthesia, and the oral surgeon removed the displaced tooth and several spicules of bone via an intraoral approach. Healing was uneventful.

DISCUSSION

When managing an oral-facial injury, priority should be given to removing avulsed teeth, fragments of tooth or bone, dental prostheses or appliances, and grossly loose teeth (not listed in sequential order). These potential foreign bodies can compromise an airway, which is of particular concern for patients with depressed mental status who may have an impaired protective gag reflex. After the patient is stabilized, the complete examination for head and neck trauma should include evaluation of the dentition for missing teeth.

If an avulsed tooth is not present in the socket and is not recovered from the accident venue, it is prudent to rule out intrusion, aspiration, or ingestion of the missing tooth.

In a review of 4 cases of fully intruded teeth in teens and adults, Tung and colleages10 reported that the causative mechanism of injury in the studied cases was high-velocity impact resulting from motor vehicle accidents. In 3 of these cases the intruded teeth were incisors; in the fourth case, the intruded tooth was a maxillary molar.

Intrusion of a tooth has several potential complications. The tooth can be impacted into the maxillary sinus or another sinus. Hara and colleagues12 described an incisor fully intruded into the frontal sinus, which resulted in sinusitis, suggesting that such an injury may lead to more complicated infection that could result in brain abscess. In the present case, intrusion of the tooth opened a direct communication into the canine space. Tung and colleagues10 also reported a case in which an intruded incisor was nearly dislodged into the patient’s respiratory tract, which could have caused life-threatening airway obstruction or a lung abscess.

If a tooth that is missing due to trauma was not recovered at the scene of the accident, and intrusion has been ruled out, aspiration and ingestion should be considered. Holan and Ram13 reported a case in which a 7-year-old girl was shown to have aspirated a primary maxillary incisor that had been avulsed and not recovered from the scene of the accident. Professional evaluation by auscultation may fail to detect an aspirated tooth.13 Should the patient develop a cough, breathing difficulty, or fever, tooth aspiration should be suspected and confirmed or excluded by means of a chest radiograph.13

If a tooth has been ingested, it is likely to pass safely through the gastrointestinal tract, but the provider should be aware that foreign body ingestion can lead to significant morbidity or even mortality. Even though 80% of swallowed foreign bodies are passed within 1 month, the remaining 20% can lead to gastrointestinal obstruction, perforation, bleeding, and sepsis.14 For locating radiopaque items, abdominal  radiographs are useful. Once an ingested tooth has been located, it is prudent to follow up with a radiograph or stool examination to ensure that the tooth has been passed.

CONCLUSION

A patient presenting with facial trauma may be distracted by other injuries, and a missing tooth may be presumed to have been avulsed during the accident but not recovered from the accident scene. However, because intrusion of a tooth can have life-threatening ramifications, any time a tooth is not accounted for, the possibility that it has been fully intruded should be considered. For diagnosing intruded teeth, the use of radiographs, supplemented by computed axial tomograms, can be helpful.

Acknowledgment

The author wishes to thank Jeffrey Lewis, MD, DMD, and Judith Hardesty for their assistance in the preparation of the manuscript.

References

1. Andreasen J, Andreasen J. Dental traumatology. Endo Dent Traumatol 1990;6:78.

2. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg. 1972;1:235-239.

3. Ravn JJ, Rossen I. Prevalence and distribution of traumatic injuries to the teeth of Copenhagen school children 1967-68 [in Danish]. Tandlaegebladet. 1969;73:1-9.

4. Gutmann JL, Gutmann MS. Cause, incidence, and prevention of trauma to teeth. Dent Clin North Am. 1995;39:1-13.

5. Jarvinen S. Fractured and avulsed permanent incisors in Finnish children: a retrospective study. Acta Odontol Scand. 1979;37:47-50.

6. Trabert KC, Caput AA, Abou-Russ M. Tooth fracture: a comparison of endodontic and restorative treatments. J Endod. 1978;4:341-345.

7. Ellis E. Soft tissue and dentoalveolar injuries. In: Peterson LJ, ed. Contemporary Oral and Maxillofacial Surgery. St Louis, Mo: Mosby; 1998:560-586.

8. Andreasen JO. Etiology and pathogenesis of traumatic dental injuries: a clinical study of 1,298 cases. Scand J Dent Res. 1970;78:329-42.

9. Turley PK, Joiner MW, Hellstrom S. The effect of orthodontic extrusion on traumatically intruded teeth. Am J Orthod. 1984;85:47-56.

10. Tung TC, Chen YR, Chen CT, et al. Full intrusion of a tooth after facial trauma. J Trauma. 1997;43:357-359.

11. Andreasen FM, Pedersen BV. Prognosis of luxated permanent teethóthe development of pulp necrosis. Endod Dent Traumatol. 1985;1:207-220.

12. Hara A, Kusakari J, Shinohara A, et al. Intrusion of an incisor tooth into the contralateral frontal sinus following trauma. J Laryngol Otol. 1993;107:240-241.

13. Holan G, Ram D. Aspiration of an avulsed primary incisor: a case report. Int J Paediatr Dent. 2000;2:150-152.

14. Kharbanda OP, Varshney P, Dutta U. Accidental swallowing of a gold cast crown during orthodontic tooth separation. J Clin Pediatr Dent. 1995;19:289-292.

Dr. Piskorowski is attending dentist, Department of Dentistry and Oral-Maxillofacial Surgery, Cayuga Medical Center, Ithaca, NY, with a  private practice in Ithaca. Dr. Piskorowski graduated from Cornell University and Marquette University School of Dentistry. He completed an advanced education in general dentistry residency while serving in the US Air Force. He can be reached at (607) 257-5941.

Practitioners often encounter a frank carious lesion needing restoration if the “wait-and-see” philosophy is used. Unsealed occlusal surfaces with early enamel lesions have a 4 times higher chance of developing dentinal lesions, according to one study.2 Also, according to Washington Dental Service, children who develop cavities on their molars will require an average of $2,187 to maintain each filling over their lifetimes.3

Clearly, preventing caries on erupting molars can have a profound public health benefit. Glass ionomer sealants have several potential advantages over resin sealants, including their ability to bond to tooth structure without the etching, rinsing, and bonding steps, and their ability to be used in areas of minimal isolation. Glass ionomer cement (GIC) is the only hydrophilic restorative material available;4 it leaches fluoride, strengthening enamel against future acid attacks, and may be bactericidal. Glass ionomer also reduces demineralization and at the same time increases remineralization.5 GIC sealants can serve as fluoride reservoirs in the oral cavity and contribute to retaining a low fluor-ide level in oral fluids, thereby contributing to the remineralization process of other teeth as well decreasing the incidence of dental caries.

The case described below uses Fuji GC Triage (GC America), which has a salmon pink shade that improves visibility during application and enables future inspection for retention evaluation. Another feature of Triage is its “command set” property, which can reduce set time by 30%. It also has a fluor-ide release level that is reportedly 6 times that of any other glass ionomer.6  The self-mix application of this glass ionomer cement sealant not only helps prevent caries on the partially erupted molar, but strengthens the enamel surface, making any future treatment of the tooth potentially more successful.

An 11-year-old female patient presented for a routine examination. Radiographs were unremarkable other than showing normally developing second molars not quite into the plane of occlusion. Clinical examination revealed partially erupted second molars Nos. 18 and 31 with significant amounts of plaque in an otherwise relatively clean mouth (Figures 1a and 1b). These teeth had relatively deep occlusal grooves retaining notable amounts of plaque. No carious lesions were detected with visual examination done with 3.5x power loupes; bite-wing radiographs were not indicated due to the patient’s orthodontic brackets. A review of prior bite-wings and a  panoramic radiograph was negative for interproximal caries. Periodontal evaluation was within normal limits, and medical history revealed no significant findings.

This patient had no prior incidence of carious lesions in permanent teeth, however, several fillings had been placed in her primary teeth. Resin sealants were noted on teeth Nos. 3, 14, 19, and 30. The patient also had full-mouth orthodontic appliances. A caries risk assessment placed this patient into the moderate range. The teeth were cleaned with a DENTSPLY Prophy-Jet with sodium bicarbonate and water slurry to remove as much plaque as possible prior to DIAGNOdent (KaVo) evaluation. DIAGNOdent readings on teeth Nos. 18 and 31 were 17 and 15, respectively.

Alternative treatments were explained to both the patient and parent. These included waiting and watching, or placement of a glass ionomer sealant to remineralize and strengthen the newly erupting molar. Both the parent and patient opted for GIC sealants despite the fact that the average longevity for the sealant to stay in place would be less than 2 years. Ideally, a resin sealant could then be placed on each of these teeth. They also understood that placement of the sealants would contribute to a stronger occlusal surface.

TREATMENT PROCESS

Figures 2. Prophy-Jet polish of occlusal surface. Care must be taken to avoid gingival bleeding.	Figures 3. Manipulation of Triage on occlusal surface with microbrush.
Figures 4. Immediate postoperative view.	5a.

Figures 5a and 5b. Similar case at 12 months. While a portion of the glass ionomer sealant has been lost on tooth No. 18, the DIAGNOdent reading is only 7.

Each side of the mouth was isolated with the Isolite (Isolite Systems), and each lower second molar was treated individually. The teeth were cleaned with a DENTSPLY Prophy-Jet with sodium bicarbonate and water slurry to remove plaque, being careful not to disturb the gingival tissue adjacent to the occlusal surface in order to minimize bleeding (Figure 2). The teeth were then dried with a stream of air, and a capsule of GC Fuji Triage was activated, triturated for 20 seconds, and placed on the occlusal surface of the tooth. This increment of Triage was carefully teased under the gingival operculum and on the exposed occlusal surface with a microbrush (Denbur; Figure 3). Following placement, a halogen curing light (Kerr/Demetron) was used in close proximity to the sealant for 20 to 40 seconds to initiate the “command set” from the heat of the light. After 105 seconds of setting time, the material was hard enough to evaluate and adjust occlusion (Figures 4 to 5b).

DISCUSSION

Although it is generally acknowledged that a resin sealant is retained longer than a glass ionomer sealant, the end result is similar.2 This can be attributed to the enamel’s fluoride uptake while in contact with the GIC and the potential of a small amount of GIC to remain in the deep fissure of the tooth. In an erupting molar, it is not possible to resin bond successfully to aprismatic, hypocalcific, or demineralized enamel.1 Thus, patients needing sealant protection for caries prevention are the least likely to have long-term retention of traditional resin sealants. Despite the inevitable loss of the GIC sealant, the enamel surface will subsequently be stronger and more caries resistant, regardless of future treatment.2 Therefore, sealing newly erupted permanent molars with high-filled glass ionomer may be a caries-preventive measure especially appropriate for high-risk children.

References

1. Milicich G. The dawn of a new era. Presented at: World Congress of Minimally Invasive Dentistry. August 2004; San Francisco, Calif.

2. Taifour D, Freneken JE, van’t Hof MA, et al. Effects of glass ionomer sealants in newly erupted first molars after 5 years: a pilot study. Community Dent Oral Epidemiol. 2003;31:314-319.

3. Dental money pit: the $2000 Cavity. Check Up (A Quarterly Newsletter). Boston, Mass: Delta Dental Dental Plan of Massachusetts Publication; Spring 2005:3.

4. McLean JW. Clinical applications of glass-ionomer cements. Oper Dent. 1992;5(suppl):184-190.

5. Chadwick BL, Treasure ET, Playle RA. A randomised controlled trial to determine the effectiveness of glass ionomer sealants in pre-school children. Caries Res. 2005;39:34-40.

6. Herle GP, Joseph T, Varma B, et al. Comparative evaluation of glass ionomer and resin based fissure sealant using noninvasive and invasive techniques: a SEM and microleakage study. J Indian Soc Pedod Prev Dent. 2004;22:56-62.

Dr. Evans is a fellow in the AGD, the World Congress of Minimally Invasive Dentistry, and The World Clinical Laser Institute. He maintains a private practice of 25 years in Chewelah, Wash. He can be reached at (509) 935-8642 or drbud@chewelahdentistry.com.

To comment on this article, visit the discussion board at dentistrytoday.com.

One reason for this is that those children who show little or very poor home care compliance are also those who are afraid of dental treatment. It is difficult to motivate these children to receive effective treatment. One way of motivating them is to use colored fillings. When it comes to providing an incentive to those children who are less nervous and who simply refuse treatment on principle, the deciding factor is the colored filling.

Using clinical examples, the following reports demonstrate that compliance in children with carious lesions in their deciduous teeth can be greatly improved, and a valid treatment completed, when colored fillings are placed. A special compomer is now commercially available to make this possible.

THE INCENTIVE FOR KIDS: CHOICE OF COLORS

Figure 1. Twinky Star color palette.	Figure 2. Color palette by Dr. Schafer and Silke Roehr.

Allowing the young patient to choose the color of a restoration gives him or her the opportunity to take part in the procedure. The color options available using Twinky Star compomers (VOCO America) range from a natural tooth color with sparkle, to pink, blue, and green (Figure 1). In order to give the children a better idea of what a tooth with a colored filling looks like, and to make it easier to choose, we have created our own color palette (Figure 2).

Choosing colors makes for an event that leaves a lasting impression. On the next visit the children often ask or inform the dentist, ‘I think I know what color I want, but I’ll have another look just in case I change my mind.’

CLINICAL EXAMPLE

Figure 3. Initial condition of tooth.	Figure 4. Condition following excavation.
Figure 5. Total etch.	Figure 6. End result.

It is especially true for young children that they can only tolerate heteronomous behavior for a certain amount of time, leaving only a short time span within which the dentist can perform the procedures. Therefore, the dentist needs to work quickly. The clinical procedure for placing colored restorations involves cavity excavation followed by etching for 60 seconds with 35% orthophosphoric acid (Vococid, VOCO America, Figures 3 to 5). The etched cavity is treated with either Solobond Plus or Solobond M (VOCO America), and the filling material is selected according to the size of the cavity. The material is then applied in one or a series of layers before being light-cured for 40 seconds. The selection of bonding agent and filling material depends on the patient’s cooperation. Finally, the filling is polished using a fine grain diamond and rubber polisher (Figure 6).

THE POLISHING PROCESS

In the case of very young children it is not always possible to polish the filling immediately after insertion, as there is a significant decline in the child’s cooperation as time progresses. In such an event polishing is postponed until a later visit. In some cases the children are so fidgety that polishing is completely omitted. With these children the time span available is so limited that work on other untreated teeth must be a priority. Despite these unpolished restorations not being optimal, we have noticed that the marginal quality is nevertheless very high.

Figure 7. Unpolished palatal and occlusal fillings.

One 4-year-old female patient did not even tolerate a single polishing instrument in her mouth. The finishing and polishing stages were therefore completely omitted (Figure 7). The palatal filling (Figure 7) was completed following excavation by hand, followed by etching and application of adhesive in single layers, then curing. Six months later the 2 occlusal cavities were treated. In the meantime, the patient allowed treatment using rotating hand instruments. A procedure using water cooling was not yet acceptable, but excavation with a round bur was possible for a very short time. The occlusal filling in one tooth was left similarly unpolished, with the occlusal filling in another tooth being briefly polished with a yellow, fine grain diamond and a synthetic polisher. Despite not having been polished 6 months previously, the palatal filling still showed good marginal adaptation.

Figure 8. Initial condition of tooth.	Figure 9. Tooth following excavation. Adjacent tooth previously treated using Twinky Star silver.
Figure 10. Use of the total-etch process with 35% orthophosphoric acid.	Figure 11. Completed filling using Twinky Star silver.

In the case of children who have accepted the idea of treatment, colored fillings show very good results. The following is a prime example. One 4-year-old who had already experienced the Twinky Star treatment (Figure 8) was quite happy to receive a second filling in the adjacent tooth (Figure 9). Following total etching (Figure 10), the cavity could be worked on without difficulty (Figure 11).

CONCLUSION

Figure 12. Follow-up after 6 months.

The examples in this article demonstrate that the use of colored compomers in children can be a valuable motivational tool. The success of the treatment is aided even further by the dentist’s explanation to the children that the fillings will continue to look good as long as the patient properly maintains them. Since the children are usually very proud of their new fillings, the idea is to encourage maintenance of them, so that by educating both children and parents a significant improvement in general oral hygiene is achieved. At the 6-month follow-up visit it was noted that those children who first appeared with multiple carious lesions and a high degree of caries were now showing only a few new carious lesions in comparison. Figure 12 is a good example, which shows results at the 6-month follow-up visit. When the tooth was filled at the start of treatment, the patient was only moderately cooperative (the patient appeared at the clinic with a toothache). During the following 3 visits, 2 teeth were sealed and 2 teeth received fillings. Acceptance grew with each visit, so that by the end of treatment a satisfactory filling in another tooth could be placed.

Reference

1. Kr’er N, Frankenberger R. F’lungstherapie im milchgebiss. Oralprophylaxe & Kinderzahnheilkunde. 2004;2:78-84.

Dr. Schafer is a dentist in the department for periodontology, operative and preventive dentistry at the University of Bonn in Germany. She can be reached at Christine.Schaefer@ ukb.uni-bonn.de.