1

The Hall Technique: Food for Thought

A novel technique using preformed metal crowns for managing

carious primary molars in general practice – A retrospective

analysis. Innes et al. BDJ (2006) 200: 451-454. No local analgesia or tooth preparation Ultraconservative (no) caries removal; sealed under SSC

2

Hall’s Clinical Trial Design

Patient

1 toothTreated with crown

Contralateral toothtreated with filling

Age 4-9; good quality radiographsMatched decay in similar teeth

procedure detailsrecorded

procedure detailsrecorded

3

Hall’s Clinical Trial Algorithm

treatment appointment

1 year recall

2 year recall

emergency appointments

recorded

emergency appointments

recorded

4

Hall Technique Procedure

● Child upright● Smallest size of

crown which would seat was chosen

● Should cover all cusps with feeling of “spring back”

● No attempt to seat crown at try in

5

Hall Technique Procedure, cont● Crown placed over tooth

and partially seated until crown engaged with the contact points

● Finger removed and child encouraged to bite into place

• Or crown fully seated with firm finger pressure alone

● Extruded cement removed from margins

● Child asked to bite firmly on the crown for 2 – 3 minutes or crown held with firm finger pressure

6

Results from DDS View

Dentists’ estimation of

discomfort experienced by child

Hall Technique

Conventional Technique

1 - no apparent discomfort 61 33

2 - very mild, almost trivial 32 36

3 - mild, not significant 25 34

4 - moderate, but child coped 12 23

5 - significant and unacceptable 2 6

Total number of patients 132 132

7

Preferred Technique by DDS, Child and Parent

Patient/ carer/ dentist preference (n= 132)

83

97

28

17

23

9

32

12

95

0

20

40

60

80

100

120

child parent dentist

Hall technique

Conventional technique

No preference expressed

Child Parent Dentist

8

The PedoNatural Crown

The Future?Esthetic full coverage restorationsUsed with a GIC and acrylic systemCrown form concept has adaptable margins and reported good seal and strength

Pre-op Post-op Crown Forms

TM

www.PedoNaturalCrown.com

9

Summary of Evidence

● SSCs outlast other restorations● Manipulation of the tooth and the crown can

be minimalized with no apparent effect on quality

● No posterior non-metal crown has been shown to perform as well as the stainless steel crown

10

Shadow of a Doubt: A New Clinical Dilemma in Composite

DentistryComposite dentistry has created a new set of clinical dilemmas for the pediatric dentist. Caries sealed into teeth is advised to be arrested. Shadows under sealants may be stain or caries. Radiolucencies under various composite formulations may be bases, caries or voids.

11

Shadow of a Doubt: Evidence?

● Reseal all broken sealants● Caries is arrested under

sealants● Visual caries diagnosis is as

good as explorer or digital● Composite longevity

<amalgam< stainless steel crown

12

Today’s Teen Dilemma: Treating Incipiencies in Permanent Teeth

The advent of “Dew Mouth” and similar carbonated beverage related caries patterns challenges the pediatric dentist’s traditional skills to manage these with least invasive techniques

13

Beyond Prevention But Before Restoration – Resin Infiltration

● When bitewings show incipient lesions beyond remineralization

● Hydrochloric acid (15%) for 90-120 seconds

● Infiltrate with fluid resin, floss excess away and light cure

● Preliminary evidence suggests that enamel is resistant to decalcification

14

Does It Work: Early Results

Paris S, Meyer-Lueckel H. Radiographic comparison of lesion progression after infiltration and standard therapy – in vivo-18 months follow-up.

● Split mouth design● One tooth received infiltration● All patients were instructed on

F toothpaste use and flossing

15

Management of Occlusal Surfaces

● No compelling evidence for how best to manage these surfaces on young permanent teeth

● Risk assessment has marginal sensitivity and specificity• We really don’t know which teeth should be sealed,

receive enameloplasty, or have composites placed● The type of composite (filler content) is also a clinician’s

choice● The use of bases also has little evidentiary support

More Fluoride Myths ?

Fluoride use in infants and pre-school aged children is controversial. Mechanisms of action and dosages continue to be debated. Initial fluoride supplement dosages were empirical. Fluoride is ubiquitous in a child’s diet. Fluorosis reports are increasing. Should caries risk of children be performed before fluoride prescribing? The ‘shotgun’ approach is no longer acceptable. Is fluorosis preferable to caries? Should non-dentists apply fluoride varnish? We are ‘floundering in a fluoride fog’! Will EBD lead us out of the fog?

MYTHBUSTERSMYTHBUSTERS

Trooth-Trooth-bustersbusters

Recent fluoride factoids

● Bottled water and caries increase.● Formula, breast milk and fluoride.● Risk periods for dental fluorosis● Fluoride toothpaste- a pea, a smear or none?

Bottled water and caries

● Bottle water sales leveled off in 2008.

● Most bottled water has little fluoride.

● FDA ‘health claim’ for bottled water?

● Evidence?● No conclusive evidence of

an association between increased caries and bottle use.

1. Cochrane- nothing

2. ADA EBD- nothing

3. PubMed-

• An investigation of bottled water use and caries in the mixed dentition.

• Broffitt B, Levy SM, Warren JJ, Cavanaugh JE.

• J Public Health Dent. 2007 Summer;67(3):151-8.

• For the dental patient. The facts about bottled water.

• J Am Dent Assoc. 2003 Sep;134(9):1287.

Formula, breast milk and fluoride

Myths or facts?● Breast milk has little fluoride.● Infant formula should be mixed

with fluoride free water.● Soy based formula has little

fluoride.● All infants should receive a

fluoride supplement beginning shortly after birth.

● Pregnant mothers should receive a fluoride supplement.

Evidence● Breast milk- 0.02 ppm. Koparal et al 2000

● Fluoride in infant formula causing fluorosis- weak evidence.

Hujoel et al 2009

● Soy based formula-up to 0.70ppm. Pagliari et al 2006

Prenatal fluoride supplements have no benefits Leverett et al 1997

● Reexamine the use of fluoride supplements during the first 6 years.

Ismail and Hasson 2008

Risk period for dental fluorosis

● Cochrane Collaboration:

1. Topical fluoride as a cause of dental fluorosis in children (In preparation)May CM Wong1, Anne-Marie Glenny2, Boyd WK Tsang1, Edward CM Lo1, Helen V Worthington2, Valeria CC Marinho3

ADA EBD:

1. Fluoride supplements, dental caries and fluorosis: a systematic review Ismail AI, Hasson H. Journal of the American Dental Association. 2008; 139(11):1457-68

2. Risk periods" associated with the development of dental fluorosis in maxillary permanent central incisors: a meta-analysis Bardsen A. Acta Odontol Scand. 1999; 57(5):247-56

PubMed:

1. Fluoride supplements, dental caries and fluorosis: a systematic review.

Ismail AI, Hasson H.

J Am Dent Assoc. 2008 Nov;139(11):1457-68.

2.Considerations on optimal fluoride intake using dental fluorosis and dental caries outcomes--a longitudinal study.

Warren JJ, Levy SM, Broffitt B, Cavanaugh JE, Kanellis MJ, Weber-Gasparoni K.

J Public Health Dent. 2009 Spring;69(2):111-5.

3. Timing of fluoride intake in relation to development of fluorosis on maxillary central incisors.

Hong L, Levy SM, Broffitt B, Warren JJ, Kanellis MJ, Wefel JS, Dawson DV.

Community Dent Oral Epidemiol. 2006 Aug;34(4):299-309

EB response:

Maxillary permanent central incisors appear most at risk from fluoride during the first 24 months of life, especially between 6 and 24 months.

Timing is important but the cumulative duration of a fluoride level must also be noted.

Duration of fluoride exposure rather than the specific period better explains the development of fluorosis.

22

Ribbon, Pea or smear- how much toothpaste on the

brush?

● Ribbon of 1000ppm F toothpaste=1g=1mg of fluoride

● Children under 6 years swallow 24-60% toothpaste from their brush

● Pea size amount= ¼ g● Unregulated amounts of fluoride

toothpaste can contribute to fluorosis 1. Prevention and management of

dental decay in the preschool child. SIGN 2005

2. Fluoride recommendations for high-risk children MCHB- DHHS 2007

3. Guideline on Fluoride therapy. AAPD 2008.

1. Brushing twice a day- one just before bed and supervised

2. Smear for high risk children under 2 years

3. Pea sized amount for children 2-5 years.

4. Rinsing after brushing should be kept to a minimum

5. Tooth brushing should began as soon as the primary teeth erupt

6. No evidence to support the ‘wiping’ of the infants predent alveolar ridges

23

25

Medical Advances in Pediatric Health

MYTHBUSTERS

Trooth-Busters

26

Myths About Devices

“If it’s embedded, it’s premedded”

is a common misconception in

dentistry. With more foreign

objects being used in pediatric

health care, what is the evidence

for using antibiotics?

27

VP Shunts: Anything New?

● Used for CSF drainage● Classically have been

premedicated with ABs● Now may have electronic

controls so sensitive to some office devices

• No need for ABs except maybe in first six months while epithelialization is taking place

28

Baclofen PumpContinuous Medication for CP

● Baclofen is a muscle relaxant to address spasticity in CP

● The baclofen pump system is intrathecal delivery of GABA

● The system is a catheter and pump - a round metal disc, about 1 inch thick and 3 inches in diameter surgically placed under the skin at the abdomen

• No IE coverage needed

29

Gastrostomy (GT) Feeding: Why?

● Used for children with global delays with poor oral motor function

● Efficient feeding takes far less time

● Better nutrition because actual intake measured

● Minimizes aspiration of food and bacteria into lungs

30

Why So Much Calculus?● Salivary gland changes?● Decreased saliva flow due

to medications?● Chronic state of

dehydration?● Lack of hygiene?● Lack of chewing and food

abrasion?● Increased serum calcium?

31

Managing Calculus Build UpEvidence on more frequent cleaning:● Jawadi A et al. found that there was an

association between calculus and aspiration pneumonia (AP)

● Brown L et al. found that use of an OTC tartar reduction dentifrice was more effective than regular fluoride-containing child toothpaste in preventing calculus accumulation in tube fed children

● Calculus reduced > 50% with TCTP

32

Imaging: What You Need to Know● MRIs are distorted because of

metallic dental restorations, but do not compromise treatment

● Increased use of interventional radiology and 3D imaging make this an issue

• Is CT or MRI needed for improved outcomes?

• Cone beam CT and risk of future cancers and evidence of any benefit – medicine is seeing a rash of new unexpected cancers now being attributed to CAT scans

Vitamin capsule

ssc

Titanium implant

33

Non-Invasive Heart Procedures

● Pacemakers● Stints and other

devices● Ask the MD• The underlying heart

disease is usually the determinant of need for IE

34

Other Concerns

● Pacemakers and other programmable devices are susceptible to electromagnetic radiation

● Shielding and refinements in cellphones and devices reducing risk

• No IE coverage needed

35

What About Solid Tumors?

● Limb sparing rather than amputation is becoming more common in bone tumors

● Consult with heme/onc MD about antibiotic coverage

36

MD/DDS Joint-Joint Statement• American Dental Association/American Academy of

Orthopaedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. JADA 2003;134:895-9.

● This was update of 1997 policy● No antibiotics for pins, plates, and screws and none for most● The risk-benefit ratio for use of antibiotics does not support

use in joint replacement patients● Might consider use of antibiotics if patient is

immunocompromised , in first 6 months post-operatively or has a history of previous replacement gone bad due to infection

● Consult with orthopedic surgeon when in doubt

37

What is a Vagal Nerve Stimulator ?

● Alters blood flow in thalamus● Thalamic blood correlated

with seizure thresholds● Exact mechanism of action is

unknown…● Intractable epilepsy● Treatment-resistant clinical

depression• No IE coverage needed

38

Central Venous Access Devices● CVADs may be used in

cancer, cystic fibrosis, IDDM, bleeding disorders for TPN, blood products and sampling

● AKA: in-dwelling cath, Hickman, Broviac, Medi-port

● Prone to infection but almost always due to skin organisms

• Antibiotics are not necessary and in fact discouraged

39

Cochlear Implants

40

Cochlear Implants: What Do I Need to Know?

● If infected, probably due to OM or skin organisms

● Chorda tympani injured in about 40% of surgeries so taste may be altered temporarily

• No antibiotic premed is needed

41

Juvenile Diabetes: The Pump

● Insulin pumps are becoming more common

● Patients with pumps went from 6600 to 195,00 from 1990-2002

● Clinically shown to reduce hypoglycemia and glycosuria

● Provide insulin small doses into abdominal subcutaneous fat

• No antibiotic coverage needed

42

I’m No Slug – I Know My Drugs!

But Do You?

Pediatric care has advanced rapidly and many medications are being re-examined for use in conditions previously treated with other medications – some may surprise challenge your understanding of disease pathophysiology

43

Botox: Hope for Sialorrhea?

Jongerius et al: Effect of botulinum toxin in the treatment of drooling: a controlled study. Pediatrics 2004;114(3):620-27.

● Both transdermal scopolamine and injected Botox reduced drooling but Botox had fewer and less significant side effects

● Maximum effect was at 2-8 weeks post-injection

44

Botox: Replacing Surgery for Limb Contractures in Cerebral Palsy

● Abnormal muscle balance in CP leads to contractures

● Selective dorsal rhizotomy and tendon release surgery may be replaced by Botox

45

Botox: Self-Mutilation Management

● Botox is being tested to reduce neuropathologic chewing in cases of closed head injury, toxic coma, and other neurologic conditions

● Botox offers the advantage of localized rather than systemic effects

46

Methotrexate: Low Dose Use

● Traditional anticancer drug used in many pediatric cancers

● Now used for rheumatoid arthritis, psoriasis, cancers, lupus and other immune-based disorders

• Always check blood counts

47

Thalidomide: For Immune Disorders

● Thalidomide caused an epidemic of phocomelia in Great Britain in the second half of the 20th century when used by pregnant women for nausea

● Children, adolescents and young adults with refractory JRA, psoriasis, severe ulcerative conditions, sickle cell and lupus may take thalidomide

• Sarmadi M, Ship JA. Refractory major apthous stomatitis with systemic immunosuppressants: a case report. Quintessence Int 2004;35:39-48

48

What About Induced (Intended or Not) Hypocoagulation

● Aspirin and Coumadin for heart disease

● Aspirin or similar compounds for joint pain in JRA

● Heparin for dialysis at any age (can be reversed)

● Discontinuation for dental surgery not always necessary

● When taking low dose for reduction of platelet aggregation, may not be necessary

• Blood tests such as bleeding time and platelet function tests unreliable

49

Aspirin: Keep Taking It!Douketis JD, Berger PB, Dunn AS et al. The perioperative management of antithrombotic therapy. American College of Chest Physicians’ evidenced-based clinical practice guidelines (8th edition). Chest 2008;133:299S-339S.

● No need to discontinue aspirin for dental procedures● No need to do platelet function assays which may be

equivocal● Be sure to advise the MD because it may be assumed ASA

will be stopped● Nasal intubation is not contraindicated in patients taking

low dose ASA

50

Flip-Flop for 1st Line Asthma Drugs

• Redding GJ et al. Changes in recommended treatment for mild and moderate asthma. J Family Pract 2004;53:692-700.

● Children with exacerbations < 6 weeks apart, > 4 episodes of wheezing per year and have risk factors of atopy, allergic rhinitis and wheezing qualify for controller therapy and are considered to have persistent asthma

• Inhaled corticosteroids now the first line of defense● ICs improve lung function● Cromolyn not considered front line● Long-acting beta-2 adrenergic agonists no longer used as monotherapy

because of lung deterioration