___________________________________ DCA06DT Dental Treatment of Pediatric and Adolescent Patients
The prevention of dental caries remains the ideal approach. Teaching patients and their parents about the basic tenets of oral hygiene and motivating them to maintain periodic recall appointments are important parts of this preventive practice. An initial clinical and radiographic examination will reveal the presence of caries and the risk of developing future caries. Statistics have shown that decay in the pits and fissures causes about 80% to 90% of all caries in the permanent posterior teeth and cause approximately 44% of all caries in deciduous teeth [9]. Pits and fissures are more plentiful and pronounced in the premolars and molars, although pits of varying sizes and depths are also common on the lingual aspects of the maxillary central and lateral incisors as well. These narrow invagina- tions in the enamel are areas in which bacterial plaque can congregate and into which toothbrush bristles may not reach. Pit and fissure sealants may be placed to decrease the risk of caries in these areas. Studies have shown that the placement of a second-, third-, or fourth-generation resin-based material can decrease the caries incidence by 88% after two years and by 79% over a span of four years, although the quality of evidence is lower at this interval [10; 80]. Teeth with deeper pits and fissures and patients with poor oral hygiene will have a greater benefit from sealants than those with excellent oral hygiene or shallow pits and fissures. When recall appointments have been kept and oral hygiene has been maintained, sealants have an 80% to 90% retention rate after 10 years and a 65% retention rate after 20 years [11; 66; 80]. Several commercial resin-based sealant products are available. Before any sealants are set, the tooth should be cleaned and the surface etched with an acidic gel that causes the enamel surface to develop microscopic porosities into which the resin will flow. This is very technique-sensitive, as salivary contamina- tion of the etched surface will preclude the development of an adequate bond strength and cause the sealant to detach. A thin layer of material is placed into the desired pit or fissure, with an ultraviolet light used to set the material. Occlusion should always be checked after sealants are placed, as any excess in the sealant height could cause a fracture of the sealant and/ or traumatic occlusion of the teeth. Dental caries can develop despite the best preventive efforts of the patient and the dental staff. The most common materials used to restore deciduous teeth without pulpal involvement are dental amalgam and composite resins. The use of either material has advantages and disadvantages, and the material of choice should be based on the restorative needs of the patient. DENTAL AMALGAM Dental amalgam has been used as a restorative dental material since the late 19th century [12]. It has been popular due to its durability, ease of placement, and low cost compared to other dental restorative materials. However, there has been controversy about the safety of dental amalgam use because
mercury is one of the composite elements, along with cop- per, tin, and silver. Patients and parents may have concerns related to the release of mercury during the placement of new amalgam restorations and the removal of deficient restorations, or the continuous release of small amounts of mercury from the material. Numerous studies and reports by the American Dental Association, the American Medical Association, the World Health Organization, the Fédération Dentaire Inter- national (FDI), and the U.S. Food and Drug Administration have affirmed the safety and efficacy of amalgam restorative material [14; 82]. Studies have shown that mercury off-gassed from dental amal- gam (approximately 2–28 mcg per facet surface per day, with 80% absorbed by the lungs) accumulates in body tissues, partic- ularly the kidneys and brain, with higher levels associated with a greater number of fillings; this represents the most prevalent source of mercury exposure for most individuals [65; 67; 68]. Evidence of debilitating systemic effects from these accumula- tions is lacking, but there is increasing awareness regarding the impact of cumulative mercury exposure, particularly on cogni- tive functioning. In 2008, both Norway and Sweden banned the use of amalgam as a dental restorative material [15]. In the United States, amalgam is still used, but some parents will not permit its use for their restorative needs or for those of their children. This debate is global in nature and will continue. Parents of minors who require restorative dentistry should always be presented with options for use of various restorative materials prior to initiation of the procedure. The preparation of the tooth and placement of an amalgam restoration will depend on whether the carious lesion occurs in the deciduous tooth of a child, the permanent tooth of a child, or the permanent tooth of an adult. Amalgam does not have the capacity to self-adhere to enamel or dentin, and the form of the cavity may not be enough to retain the amalgam restorations. In these cases, auxiliary means of retention (i.e., small slots or grooves placed at the junction of the enamel and dentin) may be necessary. While this is not a problem in the permanent teeth of adults, careful placement is necessary to avoid pulpal involvement in children and adolescents. A primary advantage of amalgam over composite resins is that it is not as technique-sensitive in its placement. If blood or saliva contaminates a tooth surface, the bond strength of a composite restoration will decrease, causing microleakage and ultimately failure. While a similar circumstance is not ideal for the placement of amalgam, the material is not dependent on a bonding process and contamination will not interfere with its setting. Amalgam is durable under compressive strength, but its inclu- sion does not strengthen the tooth. It is a restorative material, not cosmetic, and its appearance will worsen over time as intra- oral oxidation reactions cause it to darken. Larger amalgam restorations can also impart a gray or black discoloration to the adjacent enamel.
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