Review Pedo II F 2023 PDF

Review Pedo II F 2023 Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  Morphologic & histological differences in primary teeth as compared to permanent teeth Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Retrieval...

Review Pedo II F 2023 Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  Morphologic & histological differences in primary teeth as compared to permanent teeth Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Retrieval Practice How do differences in primary teeth morphology affect tooth preparations ? Chargement… What are the modifications for adhesive Cavity preps in primary teeth as compared to permanent teeth? Smaller and shallower, due to primary teeth being smaller in all dimensions and having thinner enamel Higher risk for pulp exposure especially in the mesial pulp horn Interproximal box extended into proximal self cleansing areas due interproximal surfaces rather than contact points to avoid recurrent caries Retrieval Practice How do differences in primary teeth root morphology and pulp affect child patient management? Chargement…  Root Morphological Differences primary & permanent teeth PRIMARY vs PERMANENT Longer and thinner Outward divergence of roots in order to leave space for the permanent tooth germ Physiologic Root Resorption Exfoliation  Pulp Differences primary & permanent teeth Primary teeth Permanent teeth Closer to outer surface, Mesial closer than distal Position of pulp Porous: accessory canals lead directly into inter radicular Rare furcation , pathology inter radicular Floor PA pathology Cellularity & Vascularity of pulp High Less Repair potential of pulp High Less  Pulp Differences primary & permanent teeth Primary teeth Permanent teeth Apical Foramen Enlarged Restricted Higher Inflammatory response Nerve fibers Terminate at the May extend beyond pre- odontoblastic area as dentin Innervation free nerve endings Localization of orofacial Less More infection Poor Localized Primary Teeth Larger pulps Primary Pulp horns are nearer to the occlusal surface Teeth Pulp exposure especially in the mesial pulp horn 1st primary molar 1st permanent molar  Tooth Isolation in Pediatric Dentistry Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Retrieval Practice Rubber Dam Chargement… What are the essential tools & materials to place the rubber dam in PD ? Elastic sheet Punch Forceps Clamps Dental floss Rubber Dam Frame Excavator  RUBBER DAM One of the most effective ways of isolation, Barnum1864 ADVANTAGES Patient Protection from swallowing/aspirating foreign objects Soft tissues protection Assists the child in keeping the mouth open More comfortable dental treatment  RUBBER DAM ADVANTAGES Dentist Moisture control, saliva & blood contamination Aseptic operating field, protection air born infections Better accessibility and visibility, patient in flat position Higher quality adhesive restorations Less fogging of the mirror  RUBBER DAM Contraindications Upper respiratory tract infection, congestion Epilepsy Pt is a mouth breather, modify rubber dam Latex allergy (only for the latex sheet)  Clamps in Pediatric Dentistry for anteriors 00 Ivory Primary incisors 0 Ivory Primary incisors Primary canines 1A, 3A Ivory Primary canines  Clamps in Pediatric Dentistry for posteriors 14Α Ivory 1 st permanent molar 14 , 8Α Ivory 1 st permanent molar under eruption 2 nd primary molar 2A, 27 SS White, 1 st primary molar 208 2 nd primary molar 26 SS White , B2  Which are the most common Rubber dam placement methods? Clamp Elastic sheet Rubber Dam frame Clamp + Elastic sheet Rubber Dam frame Clamp + Elastic sheet + Rubber Dam frame  Restorative materials in Pediatric Dentistry Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  Retrieval Practice How do differences in primary teeth morphology affect tooth preparations ?  CROWN Morphological Differences primary & permanent teeth PRIMARY PERMANENT Crown size Smaller Shape Buccal and lingual surface converge to the Present mamelons occlusal surface Clinically, the largest perimeter is in the Contact Points cervical region Interproximal Surfaces contacts What are the modifications for adhesive Cavity preps in primary teeth as compared to permanent teeth? Smaller and shallower, due to primary teeth being smaller in all dimensions and having thinner enamel Higher risk for pulp exposure especially in the mesial pulp horn Interproximal box extended into proximal self cleansing areas due interproximal surfaces rather than contact points to avoid recurrent caries Primary Teeth Larger pulps Primary Teeth Pulp horns are nearer to the occlusal surface Pulp exposure especially in the mesial pulp horn 1st primary molar 1st permanent molar ps in primary teeth: Preparations for adhesive restorations in primary teeth are What and o be smaller are the modifications shallower for adhesive as compared to those inCavity preps permanent in primary teeth, due to teeth as compared to permanent teeth? eth being smaller in all dimensions and having thinner enamel. Further more, Interproximal box extended into ns are to be extended well into interproximal self cleansing proximal areas to areas self cleansing avoid to avoid aries, attributed Smaller andtoshallower, primary teeth due to contacting primary recurrent through caries interproximal surfaces teeth being smaller in all dimensions Interproximal surfaces rather than contactand points. having thinner enamel contact points  Comparison between restorative materials on primary molars after 4 years service Annual Success rate % CL I 92.4 CL II 85.3 Rubber Dam Yes 93.6 Rubber Dam No 77.5 Bisphenol A (BPA) Trace amounts of BPA derivatives are released from dental resins through salivary enzymatic hydrolysis and may be detectable in saliva up to three hours after BPA exposure reduction Certain BPA derivatives may pose health risks Cleaning filled surfaces with attributable to their estrogenic properties pumice and cotton roll and rinsing Using the rubber dam  Retrieval Practice For what type of cavities is GIC recommended in restoring posterior primary teeth? CL I and CL V For a classic Cl II preparation for adhesive materials, what is the maximum recommended isthmus proportion to intercuspal distance in primary teeth ? Less than ½ of the intercuspal distance According to the Chesini et al 2018 systematic review, Chargement… is the success rate of CL I and II fillings when placed under rubber dam after 4 years in service over 97% ? No it is 93.6% Rank the restorative materials according to their annual failure rate form the highest to the lowest. Glass ionomer, composite, stainless steel crown, According to the Chesini et al 2018 systematic review, Rank the restorative materials according to their annual failure rate from the lowest to the highest. Glass ionomer conventional, composite, stainless steel crown, amalgam Stainless Steel Crown Composite Glass ionomer Conventional Amalgam Restorative materials and methods recommended to be used in primary teeth  Composites – Challenges in restoring Technique sensitivity, moisture control – isolation, uncooperative ??? Contact point Unsuitable for primary teeth posterior build ups High risk patients ????? BPA concerns  Restoring primary anterior teeth Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  Retrieval Practice What are the indications for full coverage crowns when restoring anterior primary teeth? Multiple carious surfaces Incisal edge involvement Extensive cervical decalcification Pulp therapy Hypoplastic enamel  What are the disadvantages in using strip crowns for restoring anterior primary teeth ? Durability is compromised Technique sensitive Compromised Durability, loss of some or all of the crown Overall retention ~80% after 24-36 mo What are the advantages in using strip crowns for restoring anterior primary teeth ? Excellent esthetics Multiple shade selection Can be fitted in crowded spaces Ease of repair Excellent parental satisfaction What materials are recommended for restoring CL III cavities in anterior primary teeth ? Composite RMGIRMGI Durability is compromised Composite, RMGI What materials are recommended for restoring CL V cavities in anterior primary teeth ? Composite, conventional GIC, RMGIRMGI Durability is compromised Composite, RMGI  Prefabricated stainless steel crowns in Pediatric Dentistry Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Indications for SSCs Primary teeth Permanent teeth Multisurface Hypoplastic teeth that cannot be SSC as an interim restoration adequately restored with bonded until late adolescence or early restorations adulthood Endodontically treated Teeth at risk of the remaining coronal tooth structure to fracture For a 9 years old patient, when preping # 84 distally, the isthmus distance was just over ½ the intercuspal distance. Do you recommend to place a SSC? True False It depends  Name the SSC for primary teeth advantages Less time consuming Less prone to fractures Dual retention (chemical and shape) Decreased moisture sensitivity No secondary caries Long term durability  Minimal maintenance Crowns - disadvantages Poor esthetics (SSC) Gingival health (SSC) Plaque accumulation (SSC) Amount of tooth reduction  Crowns – contradictions Primary molars close to exfoliation Primary molars with more than half of the roots absorbed Teeth with mobility Unrestorable teeth Nickel allergy Comparison between restorative materials on primary molars after 3 years of service Annual Failure rate % Resin Composite 5 Glass ionomer Conventional 6.8 Compomers 7.4 Amalgam 16.3 Stainless Steel Crown 3.7 Chisini at al, 2018  What are the advantages of Hall Crown technique? No caries removal, anesthesia, or tooth preparation Reduced cost Can be fitted by inexperienced to crowns dentists  What are the challenges using Hall Crown technique? Discomfort during band separators placement Pain from biting crown into place Discomfort for a few days from occlusal interferences  Sealing the Hall Technique biofilm & caries Suitable for General Dentists No caries removal, anesthesia, or tooth preparation Discomfort during band separators placement Pain from biting crown into place UK very often procedure, where SSC unpopular 95.8 % teeth asymptomatic after 77 months Reduced cost Doua H. Altoukhi and Azza A. El-Housseiny, Hall Technique for Carious Primary Molars: A Review of the Literature, 2020  Hall crown in EUC clinics Steps No anesthesia Radiographic examination to establish tooth restorability & pulp vitality No caries Orthodontic separators for a few hours to open contacts removal Fit crown for size mesio distally, patient to bite on crown in the inter proximals Cement crown with glass ionomer or RMGI cement Inform patient for potential occlusion interferences to resolve the next few days Which cement to use for cementing a SSC? RMGI  Silver Diamine Fluoride Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Is SDF 38% recommended in Pediatric Dentistry to be used clinically as a caries preventative agent? True False  What are the indications of using SDF in Pediatric Dentistry ? Arrest of cavitated caries lesions, with NO clinical or radiographic signs of pulpal involvement As part of a comprehensive caries management program, or people with caries in situations where traditional treatment approaches to caries management might not be possible  What are the clinical effects of SDF? Caries arrest Prevent demineralization Hypersensitivity management What is SMART? Silver Modified Atraumatic Restorative treatment is a minimally invasive treatment for cavities treated by SDF and restored with GIC What is the recommended application frequency for SDF? Baseline 3 month Every 6 months for 2 years Early Caries Diagnosis using the ICDAS II diagnostic criteria Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD In how many categories is caries being evaluated in ICDAS? 6 categories What is the cut off category for diagnosing cavitated caries when using the ICDAS II ? ICDAS 5 What are the characteristics of an ICDAS 1 carious lesion? First visual change in enamel, seen only after prolonged air drying or restricted to within the confines of a pit or fissure What are the characteristics of an ICDAS 3 carious lesion? Localized enamel breakdown (without clinical visual signs of dentinal involvement) What are the characteristics of an ICDAS 2 carious lesion? Distinct Visual Change in Enamel Opacity or discoloration that is wider than the natural fissure or fossa What depth does R3 score represent when evaluating radiographically interproximal caries? Carious lesion in outer 1/3 of the dentin What is your ICDAS diagnosis for the encircled lesion? ICDAS 5 What is your ICDAS diagnosis for the encircled lesion? The tooth is not dried from saliva ICDAS 2 Pit & fissures carious lesions. Diagnosis & management using the ICDAS II caries diagnostic criteria Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  What are the materials recommended to be used in sealing primary and permanent teeth? Glass ionomer Resin Composite  List methods that can be used to isolate semi- erupted teeth when applying sealants Rubber Dam Dry Angle Cotton Roll holder Isolite What is your recommended Management of Healthy pit & fissures ? Healthy & shallow fissures Monitor ICDAS 0,1,2 Topical Fluoride Initial Caries Healthy and deep fissures Preventive sealant ICDAS 0,1,2 What is your recommended management of pit and fissures with moderate caries ? Therapeutic sealant or PRR Composite resin What is your recommended management of pit and fissures with already manifested caries ? Se Caries in dentin Selective caries ver ICDAS 4,5 & 6 Removal (Vital teeth) e and Restoration Interproximal caries diagnosis ICDAS II Radiographic criteria SCORE CRITERIA- Radiolucency IMAGE R0 No visible R1 Outer ½ of the enamel. R2 Inner ½ of enamel ± DEJ R3 Outer 1/3 of the dentin. R4 Middle 1/3 of the dentin. R5 Inner 1/3 of the dentin (cavity) R6 Into the pulp (clinically cavitated) What is your ICDAS diagnosis for the encircled lesions? R5 Inner 1/3 of the dentin (cavity) R5 R3 R3 Outer 1/3 of the dentin. What is your ICDAS diagnosis for the encircled lesions? R2 R3 R2 Inner ½ of enamel ± DEJ R3 Outer 1/3 of the dentin  What are the materials recommended to be used for sealing of primary and permanent teeth? Glass ionomer Resin Composite  List methods that can be used to isolate semi erupted teeth when applying sealants Rubber Dam Dry Angle Cotton Roll holder Isolite Criteria for succesful sealants Coverage Margins No porous Retention Bisphenol A (BPA) Trace amounts of BPA derivatives are released from dental resins through salivary enzymatic hydrolysis and may be detectable in saliva up to three hours after Certain BPA derivatives may pose health risks attributable to their estrogenic properties BPA exposure reduction is achieved by cleaning filled surfaces with pumice and cotton roll and rinsing Potential exposure to BPA can be reduced by using the rubber dam  Permanent Teeth NOC: Non Operative Care TPOC: Tooth Preserving Care https://www.iccms-web.com/  Primary Teeth NOC: Non Operative Care TPOC: Tooth Preserving Care https://www.iccms-web.com/ Early Caries Diagnosis and management of interproximal and buccal lesions using the ICDAS II diagnostic criteria Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD  SCORE CRITERIA- Radiolucency IMAGE R0 No visible R1 Outer ½ of the enamel. Diagnosis of R2 Inner ½ of enamel ± DEJ Interproximal caries based on ICDAS II R3 Outer 1/3 of the dentin. Radiographic criteria R4 Middle 1/3 of the dentin. R5 Inner 1/3 of the dentin (cavity) R6 Into the pulp (clinically cavitated)  Managing interproximal lesions when cavitation is not clinically detectable Determining Cavitation Status Chargement… Cavitation NO non operative procedures Cavitation YES operative intervention https://www.iccms-web.com/ Prevalence of Cavitation after tooth separation Cavitation after tooth separation Permanent teeth % Primary teeth % Radiographic caries ICDAS II After tooth 0 2.0 separation 60% R1 Outer ½ enamel of R3 had no 10.5 2.9 R2 Inner ½ of enamel cavity 40.9 28.3 R3 Outer 1/3 of dentin 100 95.5 Pitts and Rimmer 1992  Resin Infiltration CONCEPT A minimal invasive sealing technique used to manage buccal and interproximal smooth surface early carious lesions. Low infiltration resin penetrates into the porous enamel and prevents the formation or arrests the lesion by: Obstructing the nutritional pathway of the bacteria sealed under the resin layer and new bacteria to enter Strengthening the enamel structure Kim S., et  al 2011 Resin Infiltration mechanism Perfuses porous enamel with resin by capillary action Stops the process of demineralization Stabilizes the carious lesion  HCL Enamel etching 15% HCL gel to improve the resin permeability and infiltration of the resin By removing the pseudo-intact surface layer present By opening the pore system of the body of the lesion for the infiltrant to penetrate Hydrochloric acid 15% 40-58µm Phosphoric acid 25µm Meyer – Lueckel et al, 2007  ICON TECHNIQUE Clean with rubber cup and prophy paste ISOLATION (RD, dry-field isolation system) HCL acid gel 15% for 120s Wash away with water Dry Ethanol for 30s Apply resin infiltrant for 3 mins Wipe the excess with cotton roll and floss ICON® Manufacturer’s instructions. Light cure (40s) Infiltration Masking of Enamel WSL Enamel Refractive Index Demineralized dried enamel 1.0 Demineralized wet porous enamel 1.33 (filled with water): Sound 1.62 Pores filled with infiltration resin 1.52 Hosey MT., Deery C., Waterhouse PJ. Paediatric Cariology. London: Quintessence Essentials 2004  Vital and Non Vital pulp therapy for the management of deep caries in primary molars Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD Recommendations: Clinical Practice Guideline Coll et al, 2020  Pulp Differences primary & permanent teeth Primary teeth Permanent teeth Closer to outer surface Position of pulp Mesial closer than distal More ribbon like Less Root canal Nerve fibers Thin tortuous branching Porous: accessory canals lead directly Rare Floor into inter radicular furcation Cellularity & Vascularity Pathology inter radicular of pulp PA pathology High Less Repair potential of pulp High Less  Pulp Differences primary & permanent teeth Primary teeth Permanent teeth Apical Foramen Enlarged Restricted Higher Inflammatory response Nerve fibers Terminate at the May extend beyond pre- odontoblastic area as dentin Innervation free nerve endings Localization of infection Less More Poor Localized Vital pulp management  Primary Teeth Vital Pulpal Management History - Clinical findings Radiographi Pulp vitality Management Methods Symptoms c findings Deep caries Vital pulp Indirect pulp capping Restorable tooth No pathology Deep caries Vital pulp Pulpal Bleeding controlled Possible Periapical or Pulp exposure Intra radicular Reversible pulpitis Direct pulp capping discomfort upon < 1mm CaOH2 chewing No MTA No pain or Restorable tooth pathological minimum upon Deep caries Root Vital pulp Pulpotomy provocation Pulp exposure resorption Reversible pulpitis > 1mm Internal or MTA External Formocresol Deep caries Compromised Pulpal No hemostasis from amputated Pulp exposure Vitality pulp stums > 1mm Irreversible pulpitis Pulpectomy  Match the following success rates with the pulpal management methods % 89, 96, 87, 82, 76, 92, 83 Pulpal Management Method Success Rate Indirect Pulp Capping (2yrs) 96 Direct Pulp Capping (2yrs) 89 Pulpotomy MTA (2yrs) 90 Pulpotomy FC (2 yrs) 87 Pulpotomy in General 82 Pulpectomy 92 LSTR 76 Non Vital pulp management methods Primary teeth  Indications for pulpectomy in primary teeth Irreversibly inflamed or non vital pulp Restorable tooth Root physiologic Resorption less than 1/3 of root Cooperative patient For the 2nd primary molars in the event the permanent molar has not erupted to maintain the space and fuction For anteriors due to aesthetic reasons Steps of Pulpectomy in primary teeth Remove pulpal tissue from canal with rimers H to #35 Copious Rinsing with NaΟCl (0.5 - 2%) Working length 2 mm from apex Dry with paper points and determine length  Obturate (Lentulo ZnOE or with syringe Obturation Materials for RCT Primary teeth ΖnΟ-Ε Higher prevalence of hypoplastic anomalies for the crown of permanent teeth, RR 20% , Delayed exfoliation of primary molars (Dunston & Coll, 2008) ZnO-Ε + Iodoform Εndoflas Zinc oxide 56.5%, Barium sulphate 1.63% Iodoform 40.6% Ca(ΟΗ)2 + Vitapex, Metapex Iodoform 40.4%, calcium hydroxide 30.3%, silicone oil 22.4% Iodoform  Non Vital Pulpal management Methods of Deep caries in primary molars History - Clinical Radiographic Pulp vitality Management Methods Clinical Success % Symptoms findings findings In 18 months No Symptoms Deep caries No Root Pulpectomy if tooth Restorable Resorption ZOE ZOE 92 Discomfort /pain upon chewing Intra radicular ZOE/Iodoform/CH ZOE/Iodoform/CH 93% pathology +/- Extraction if tooth Non Restorable Root Resorption LSTR 76 >1mm Extraction Pain upon Facial Swelling Intra radicular Pulpectomy 56-69 chewing pathology +/- Mobility +/- Extraction Intra oral Fistula +/- Pulpectomy Challenges Attn not to perforate furcation or permanent tooth bud through apex Contraindications Non cooperative patient Root resorption > 1/3 Extraoral, intraoral abscess Medically compromised patient, immunosuppression Follow-up x-rays to determine success  LSTR LSTR is an alternative treatment for primary teeth with a necrotic pulp or pulp with irreversible pulpitis, when root resorption is >1/3 of the root and remaining serving time in the oral cavity is up to 12 months. Reported clinical success over a 12 months period is 76%. The procedure involves no instrumentation of the root canals but instead disinfecting the root canals by placing an antibiotic mixture (clindamycin, metronidazole, and ciprofloxacin) in the pulp chamber, before the tooth is restored.  Pulpal Management Follow up every 6 months Clinically Absence of pain, edema or mobility Radiographically yearly, PA radiograph Normal lamina dure Improvement in bone architecture intraradicularly No signs of new pathology Paediatric Department- EUC  DENTAL TRAUMA SPLINTING & PULP TREATMENT Katerina Kavvadia DDS, MS, PhD, Diplomate ABPD Konstantina Taoufik DDS, MS, PhD In which types of trauma in permanent teeth splinting is necessary Extrusion Lateral luxation Intrusion Avulsion Root fracture Alveolar fracture In which types of trauma splinting is necessary for 4 weeks Lateral luxation Alveolar fracture Which are the characteristics of the ideal splint? Which types of trauma require pulp treatment? Which are the indications for DPC & Pulpotomy Cvek? Which is the procedure for Cvek pulpotomy? In which types of trauma RCT is indicated…… HAPPY NEW YEAR !!!