Restorative Treatment for High Caries Risk Children

Daniel Ravel DDS, FAAPDFayetteville, North Carolina

Daniel Ravel DDS, FAAPD1. Diplomate, American Board of Pediatric Dentistry, since 04/19952. Fellow, American Academy of Pediatric Dentistry 3. Member, Fayetteville Dental Society4. Member, North Carolina Academy of Pediatric Dentistry

University of Illinois at Chicago. BS Biology, 05/1974. University of Illinois College of Dentistry, DDS, 08/1979. Pediatric Dentistry Residency, Fort Meade Maryland, 06/1992

Staff privileges:· Highsmith-Rainey Specialty Hospital· Southeastern Regional Medical Center· Central Carolina Hospital

Email: danielravel@hotmail.com Cell: (910) 797-1590

Lecture Overview

Determining Caries RiskBehavior Guidance BasicsLocal AnesthesiaThe Rubber DamClass II RestorationsAnterior CrownsPosterior Stainless Steel Crowns

Determining Caries Risk:Disparity in Disease Prevalence

Determining Caries Risk:Disparity in Disease Prevalence

ECC occurs disproportionately among children in poverty & those belonging to some racial/ethnic groups

ECC occurs in:5% of all children30-50% of low income children

Much more likely to go untreated in this group

79% of 2-5 yr old Native American (American Indian/Alaskan Native) children

80% of decay occurs in 20% of children

Determining Caries Risk:Risk factors

Determining Caries Risk:Parent’s socioeconomic status

Low SES: High risk

Midlevel SES: Moderate risk

High SES: Low risk

Determining Caries Risk: Caries-producing producing food/drink

Mealtimes: Low risk

1-2 snacks: Moderate risk

>3 snacks: High risk

Consumption of juice, carbonatedbeverages or sports drinks

Use of bottle/sippy cup containingliquid other than water

Determining Caries Risk:Frequency of brushing child’s teeth

<1: High risk1: Moderate risk2-3: Low risk

Behavior Guidance Basics:Effective communication

• Concise– Keep it simple and honest– Short messages– Be clear about what is acceptable

behavior

• Command– Direct the operation– Eye contact– Commands better at starting than

stopping behavior

• Concrete– Say what it is– Don’t ask questions if there isn’t a

choice

Behavior Guidance Basics:Positive reinforcement

Rewarding desired behavior☺ Verbal praise☺ Prizes☺ Facial expression

Gives appropriate feedback

Strengthens recurrence of those

behaviors

Behavior Guidance Basics:Distraction

Diverting the patient’s attention from

what may be perceived as anunpleasant procedure

≈ Find out interests

≈ Give patient a short break

Behavior Guidance Basics:Voice control

Gain the patient’ attention

Establish adult-child roles

Controlled alteration of :

Voice Volume

Pace

Tone

Behavior Guidance Basics:Parental presence/absence in operatory

__ Depends on if the parent can

help reduce the patient’s

anxiety.

__ Parental attitudes have

changed.

__ Legal reasons.

__ Do not use with parents who are unwilling or unable to extend effective support

Local Anesthesia

Body ControlOperator should be in control of patient's head - it may move

suddenly!!Hands - at side, in pockets, sit on them, hold belly button.

Topical anesthetic

Guiding the Child’s Behavior:

Have an assistant ‘block’ the child’s hands/arms

Use distraction (voice/motion)

Mandibular Block: below the plane of occlusion in the primary dentition

Mouth Props:

Long Buccal Injection

Post-Anesthesia Conditions

Blanching due to Blanching due to vasoconstrictorvasoconstrictor

Operative Setup

Rubber Dam

Should be used for pediatric restorative procedures- access and visualization- moisture control -prevent aspiration or swallowing foreign

objects- avoid soft tissue trauma- breath through nose-- better N20

management

Anesthesia for Rubber Dam

Rubber Dam “Slit Technique”

Failure of Class II Restorations

Amalgams Isthmus fracture.

CompositesRecurrent decay at

gingival margin.

Failure of Class II Restorations

Anterior Crowns

Indications

- Large proximal lesions- Pulpal involvement- Fractures - Enamel disturbances- Cervical decay which is subgingival- High caries risk

Metal Anterior SSC

Strong

Does not require much remaining tooth structure

Unesthetic

Open Face SSC

Strong

Does not require much enamel

More esthetic than traditional SSC

Requires cooperation from patient

“Open-Face” Stainless Steel Crown

Pre-Faced Anterior SSC

Strong

Does not require much enamel

More esthetic than traditional SSC

Quicker than composite facing or strip crown

Bulky

Expensive

Composite (strip) Crowns

Weak

Relatively easy to do

Not good in cases of heavy occlusal forces

Esthetic

Composite Strip Crown Technique

Composite Strip Crown Technique

Stainless Steel Crowns:Indications

Following Pulp Therapy

Stainless Steel Crowns:Indications

Large, Deep Caries Caries on 3 or more surfaces

Stainless Steel Crowns Indications:High caries risk

Large, Deep Caries Enamel Hypoplasia

1st Permanent Molars

Stainless Steel Crowns:Indications

Space Maintainers:Prefab Systems

Distal Shoe Space Maintainers

Be sure to place a bend at the tip of the distal shoe to avoid damaging the erupting premolar.

Bad Good

Crowns for Guiding Teeth

Ectopic Eruption

Crown is indicated on a second molar AND the permanent first molar is hold-type ectopic

Crowns for Guiding Teeth

Technique:Pulp treatment is completed in the usual manner.

Estimate amount of distal reduction required.

Carefully reduce so that first molar is not damaged.

Estimated reduction

Crowns for Guiding Teeth

Technique (con’t)Using perio probe,

sound the mesial of the permanent molar

Unitek crown is trimmed so that the distal margin extends below the mesial marginal ridge of the first molar. Solder???

SSC Technique

Occlusal Reduction: Adequate for Height of SSC ~1-1.5 mm

Occlusal Depth Grooves

SSC Technique

Note: Rounded Line Angles

Trimming the SSC

If SSC too long, score gingival margin & trim w/ scissors

After trimming, smooth margins with stone or wheel

SSC Adaptation

ContouringBend gingival 1/3 of SSC w/

114 or 137 plier to restore anatomic shape and reduce marginal circumference of SSC

CrimpingTuck cervical margin under

to ensure tight adaptation with 137 or crimping plier

Space loss due to caries

Compress SSC’s mesio-distally with pliers

Additional bucco-lingual reduction to fit smaller crowns

Seating the SSC

Seat lingual to buccal

Slide/snap crown over the buccal cervical bulge

ALWAYS support jaw while seating crown

Should “Snap” into Place Over Cervical Bulge

Use “band seater”

Checking for Open Margins

Confirming the Occlusion & Cementation

Fuji Plus

Fluoride Varnish Treatment

Goals for caregiver of child at high risk: