DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
In children and adolescents, preparation of the outline form for the restoration of deciduous posterior teeth is dependent on several factors. The point at which two adjacent teeth touch (i.e., the contact area) between deciduous molars is broader and flatter than the comparable contact area between permanent teeth, and this is an important consideration when placing class II restorations using amalgam or composite resin. Clinicians who are used to placing class II restorations in permanent teeth should be cognizant of these anatomic and restorative differ- ences. A class II restoration that would provide an adequate interproximal contact in a permanent tooth will not span the contact area of adjacent deciduous molars, which can lead to food impaction and an increased risk of recurrent caries. COMPOSITE RESIN Composite resin material was first introduced as a choice for the restoration of class III (interproximal lesions in anterior teeth), class IV (carious lesions or traumatic fractures of ante- rior teeth that involve the interproximal surface and the incisal edges), and class V lesions of both deciduous and permanent teeth. Numerous composite resin materials have now been developed to restore class I and class II lesions in deciduous and permanent posterior teeth. Beyond the cosmetic benefit, the use of etchants and bonding agents allows a chemical and mechanical bond to develop and secure the composite resin to enamel and dentin. Thus, less tooth structure is removed compared to amalgam, which cannot bond to enamel or dentin and relies on the reduction of additional tooth structure and retentive grooves or slots for mechanical retention. The primary considerations in the use of composite mate- rial for the restoration of posterior deciduous teeth are the additional time required in their placement, the additional cost, and the ability to isolate the tooth. As noted, the place- ment of composite resin restorations requires that the tooth be isolated from saliva and blood with a rubber dam. While this device provides excellent isolation, some patients will find it uncomfortable, feeling that it is confining and a barrier to communication with dental staff during the procedure. Children can be especially fearful of the rubber dam and may be uncooperative during its placement, which can jeopardize the successful placement of the restoration. Children may also become restless and uncooperative during the longer time required for the placement of composite restorations. If confronted with any of these situations, consider the placement of amalgam restorations in posterior deciduous or permanent teeth or referral to a pedodontist capable of sedating the patient for restorative procedures. SILVER DIAMINE FLUORIDE A relatively new product to the United States, 38% silver diamine fluoride (SDF) was approved by the FDA for use in the management of hypersensitivity, and one SDF product, Advantage Silver Arrest (Elevate Oral Care), was the first to be cleared as caries arrest treatment (off-label use) [69; 78]. SDF has been used around the world as an alternative to restorative dentistry (particularly in Japan) for more than eight decades
in people of all ages. Because SDF is a newer product in the United States, a committee of researchers and clinicians at UCSF has developed a protocol for using topical 38% SDF for caries treatment at dental clinics. The authors of the protocol describe the mechanism of action of SDF [78]: Upon application of silver diamine fluoride to a decayed surface, the squamous layer of silver-protein conjugates forms, increasing resistance to acid dis- solution and enzymatic digestion. Hydroxyapatite and fluoroapatite form on the exposed organic matrix, along with the presence of silver chloride and metallic silver. The treated lesion increases in mineral density and hardness while the lesion depth decreases. Meanwhile, silver diamine fluoride specifically inhibits the proteins that break down the exposed dentin organic matrix: matrix metallo- proteinases; cathepsins; and bacterial collagenases. Silver ions act directly against bacteria in lesions by breaking membranes, denaturing proteins, and inhibiting DNA replication. Ionic silver deactivates nearly any macromolecule. SDF may be used for caries preventative therapy in patients with salivary dysfunction secondary to aging, cancer treatment, methamphetamine abuse, polypharmacy, or Sjögren syndrome [78; 83]. SDF therapy is recommended for patients who have complications that preclude invasive restorative treatments. For children, indications for preventative therapy and treatment include extreme caries risk (e.g., xerostomia, severe early child- hood caries), treatment challenged by behavioral or medical management, and difficult-to-treat dental carious lesions based on access, isolation, and cleansability (e.g., recurrent caries at a crown margin, root caries in a furcation). An advantage of SDF is that it can be quickly applied at a diag- nostic visit; however, repeat applications are often performed at one- and three-month follow-up visits, and then at six-month semi-annual visits for two to three years [78]. Despite this, a single annual application of SDF is more effective for caries prevention than applying fluoride varnish two to four times per year or, if applied every year, than occlusal sealants [83]. For treatment of a carious lesion, the area is first thoroughly isolated using cotton or gauze; forced air may be used to ensure complete dryness, which improves efficacy. An applicator is used to place a small amount of SDF onto the lesion, where it is left for one to three minutes to soak into and react with the softened enamel and/or dentin; this timeframe is not critical but is a recommended caution for the first application. Uncooperative children have been successfully treated within only a few seconds SDF reaction time. One disadvantage to SDF therapy is that the product perma- nently stains the lesion, but no other area, a dark grey color over time as the decay arrests; the color is similar to that of dental amalgam. Patients and/or parents should be informed of this effect [78]. Another disadvantage is that the treatment does not restore function of the tooth; fillings are recommended
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