Showing posts with label Paediatric Dentistry. Show all posts
Showing posts with label Paediatric Dentistry. Show all posts

Wednesday, June 8, 2016

Atraumatic Restorative Treatment (ART) for tooth decay

Atraumatic Restorative Treatment (ART), is based on removing decalcified tooth tissue using only hand instruments and restoring the cavity with an adhesive filling material.
A minimally invasive approach to both prevent dental carious lesions and stop its further progression. 


Thursday, June 2, 2016

Guidelines on Behavior Guidance for the Pediatric Dental Patient

Safe and effective treatment of dental diseases often requires modifying the child’s behaviour. Behaviour guidance is a continuum of interaction involving the dentist and the dental team, the patient, and the parent directed toward communication and education.

Recommendations for Basic behavior guidance

Communication and communicative guidance
Communicative management and appropriate use of commands are used universally in paediatric dentistry. Communicative management comprises a host of techniques which include, tell-show-do, voice control, nonverbal communication, positive reinforcement, and distraction. The dentist should consider the cognitive development of the patient, as well as the presence of other communication deficits (eg, hearing disorder), when choosing specific communicative management techniques.

1.Tell-show-do

A technique of behaviour shaping used by many paediatric professionals. The technique involves verbal explanations of procedures in phrases  appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory,  olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do).

2. Voice control

Voice     control  is             a              controlled           alteration            of            voice         volume, tone, or pace to influence and direct the patient’s     behaviour. Parents unfamiliar with this possibly aversive technique may benefit from an explanation prior to its use to      prevent misunderstanding.                       

3. Nonverbal communication
Reinforcement     and guidance of behaviour through appropriate contact, posture, facial expression, and body language.

4.  Positive reinforcement

In            the         process of            establishing        desirable             patient     behaviour, it is essential to give appropriate feedback. Positive     reinforcement is an effective technique to reward desired     behaviours and, thus, strengthen the recurrence of those behaviours. Social reinforces include positive voice modulation, facial expression, verbal praise, and appropriate physical    demonstrations of affection by all members of the dental team. Non-social reinforces include tokens and toys.                               

5. Distraction
It is the technique           of            diverting              the         patient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behaviour guidance techniques.


Parental presence/absence

The        presence             or            absence               of            the         parent  sometimes can be used to gain cooperation for treatment. Parents’ desire to be present during their child’s treatment does not mean they intellectually distrust the dentist. It might mean they are uncomfortable if they visually cannot verify their child’s safety.  It is important to understand the changing emotional needs of parents because of the growth of a latent but natural sense to be protective of their children. Practitioners should become receptive to the involvement of parents and welcome the questions and concerns for their children.

Nitrous oxide/oxygen inhalation
Safe       and        effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction.



Adopted from the guidelines of AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Wednesday, September 16, 2015

Molar Incisor Hypomineralization


The term molar incisor hypomineralization (MIH) was introduced in 2001 to describe the clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFMs) that are associated frequently with affected incisors. The condition is attributed to disrupted ameloblastic function during the transitional and maturational stages of amelogenesis. This condition is recognized in various terms such as hypomineralized PFMs, idiopathic enamel hypomineralization , dysmineralized PFMs, nonfluoride hypomineralization and cheese molars.

Molar incisor hypomineralization


Epidemiology
The prevalence data for MIH are limited due to various diagnostic classifications. According to existing data the prevalence ranges from 4% to 25% across different populations. The number of hypomineralized PFMs in an individual can vary from 1 to 4, affecting particularly 2 or more molars including the contralateral tooth, where the teeth are moderately or severely affected. The risk of involvement of the permanent maxillary incisors appears to increase when more PFMs are affected.
Putative factors associated with disrupted amelogenesis of PFMs include systemic conditions and environmental insults influencing natal and early development specially during the child’s first 3 years.  The systemic conditions implicated to date include nutritional deficiencies, brain injury and neurologic defects, cystic fibro­sis, syndromes of epilepsy and dementia (Kohlschutter-Tonz syndrome), nephrotic syndrome, atopia, lead poisoning, repaired cleft lip and palate, radiation treatment, rubella embryopathy, epidermolysis bul­losa, ophthalmic conditions, celiac disease, and gastrointestinal disorders. Conditions common in the first 3 years, such as up­per respiratory diseases, asthma, otitis media, tonsillitis, chicken pox, measles, and rubella, are also known to be associated with MIH. Some studies suggest the association of Preterm birth with increased prevalence of enamel defects, including hypomineralization and hypo­plasia in the permanent dentition.

Clinical presentation and Diagnosis

Criteria for the diagnosis of demarcated opacities, post-eruption breakdown (PEB), atypical restorations, and extracted PFMs due to MIH were developed by Weerheijm et al. Dentitions with generalized opacities present on all teeth rather than limited to the PFMs and permanent incisors, are not considered to have MIH.

Four PFMs and 8 erupted permanent incisors are examined wet for demarcated opacities (white-cream or yellow-brown in color, of normal thickness with a smooth surface), post eruptive breakdown, and atypical restorations.
·      
     The opacities are usually limited to the incisal or cuspal one third of the crown, rarely involving the cervical one third.
·   
   Due to the unusual size and shape, restorations may not conform to typical caries patterns and frequently involve the cuspal or incisal one third of the crown.
·         Enamel opacities may occur adjacent to restoration margins.

Diagnostic Categories of MIH

·         Mild MIH
o   Demarcated opacities are in nonstress-bearing areas of the molar
o   No enamel loss from fracturing is present in opaque areas
o   There is no history of dental hypersensitivity
o   There are no caries associated with the affected enamel
o   Incisor involvement is usually mild if present
·         Moderate MIH
o   Atypical restorations can be present
o   Demarcated opacities are present on occlusal/incisal third of teeth without posteruptive enamel breakdown
o   Posteruptive enamel breakdown/caries are limited to 1 or 2 surfaces without cuspal involvement
o   Dental sensitivity is generally reported as normal
·         Severe MIH
o   Posteruptive enamel breakdown is present
o   There is a history of dental sensitivity
o   Caries is associated with the affected enamel
o   Crown destruction can advance to pulpal involvement
o   Defective atypical restoration
o   Aesthetic concerns are expressed by the patient or parent

Differential Diagnosis

Fluorosis

Amelogenesis imperfecta

Enamel hypoplasia


o   It can be differentiated from fluorosis as its opacities are demarcated, unlike the diffuse opacities that are typical of fluorosis. Fluorosis is caries resistant and MIH is caries prone and also fluorosis can be related to a period in which the fluoride intake was too high
o   Choosing between amelogenesis imperfecta (AI) and MIH: only in very severe MIH cases, the molars are equally affected and mimic the appearance of AI
o   In MIH, the appearance of the defects will be more asymmetrical and in AI, the molars may also appear taurodont on radiograph and there is often a family history.

Management

MIH’s clinical management is challenging due to:

1. The sensitivity and rapid development of dental caries in affected PFMs
2. The limited cooperation of a young child
3. Difficulty in achieving anesthesia

4. The repeated marginal breakdown of restorations.

Management of Molar incisor hypomineralization



Monday, August 31, 2015

Dental Fluorosis


Epidemiology

Dental fluorosis is a developmental disturbance of dental enamel caused by the consumption of excess fluoride during tooth development. It's caused by overexposure to fluoride during the first eight years of life more commonly, the time when most permanent teeth are being formed. 

Dental Fluorosis
Common sources of fluoride includes, toothpaste (if swallowed by young children), drinking water in fluoridated communities, beverages and food processed with fluoridated water, dietary prescription supplements that include fluoride (e.g., tablets or drops) and other professional dental products (e.g., mouth rinses, gels, and foams). Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpastes (if swallowed by young children) and dietary prescription supplements in tablets or drops. Moderate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) to drinking water is typically the most significant source. 

Dental fluorosis can occur among persons in all communities at different severities, even in those with a low natural concentration of fluoride in the drinking water. However fluoride in water is mostly of geological origin. Waters with high levels of fluoride content are mostly found at the foot of high mountains and in areas where the sea has made geological deposits. Known fluoride belts on land include: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In these areas fluorosis has been reported. Various studies from all over the world on the disease burden of different populations reveals different figures. But As of 2005 surveys conducted by the National Institute of Dental and Craniofacial Research in the USA between 1986 and 1987 and by the Center of Disease Control between 1999 and 2002 are the only national sources of data concerning the prevalence of dental fluorosis.

Data from the National Health and Nutrition Examination Survey, 1999-2004 and the 1986-1987 National Survey of Oral Health in U.S. School Children reveals that there were less than one-quarter of persons aged 6-49 in the United States had some form of dental fluorosis. The prevalence of dental fluorosis was higher in adolescents than in adults and highest among those aged 12-15. Adolescents aged 12-15 in 1999-2004 had a higher prevalence of dental fluorosis than adolescents aged 12-15 in 1986-1987. Another survey conducted in Indian subcontinent shows that fluorosis is an endemic disease prevalent in 20 states out of the 35 states and Union Territories of the Indian Republic.

Signs and symptoms

Symptoms of fluorosis range from tiny white specks or streaks that may be unnoticeable to dark brown stains and rough, pitted enamel that is difficult to clean. The severity of the condition depends on the dose (how much), duration (how long), and timing (when consumed) of fluoride intake. Since the 1930s, dentists have rated the severity of fluorosis using the following categories:
·
  • Questionable -The enamel shows slight changes ranging from a few white flecks to occasional white spots.
  • Very mild      -Small opaque paper-white areas are scattered over less than 25% of the tooth surface.
  • Mild               - White opaque areas on the surface are more extensive but still affect less than 50% of the surface.
  • Moderate        -White opaque areas affect more than 50% of the enamel surface.
  • Severe             -All enamel surfaces are affected. The teeth also have pitting that may be discrete or may run together.
Classification of Dental Fluorosis

Treatment options
Depending upon severity of the disease, treatment option varies. Micro/Macro abrasion, Bleaching, Composite restorations, Veneers, Full crowns are the main options available. These are described in detail in another article.

Disease prevention

Removal of excessive fluoride from drinking-water is difficult and expensive. The preferred option is to find a supply of safe drinking-water with safe fluoride levels. If you rely on well water or bottled water, your public health department or a local laboratory can analyze its fluoride content. Where access to safe water is already limited, de-fluoridation may be the only solution. Methods include: use of bone charcoal, contact precipitation, use of Nalgonda or activated alumina (Nalgonda is called after the town in South India, near Hyderabad, where the aluminium sulfate-based defluoridation was first set up at a water works level).


Health education regarding appropriate use of fluorides and parental vigilance is a key measure to prevent fluorosis. Keeping all fluoride-containing products such as toothpaste, mouth rinses, and supplements out of the reach of young children and monitoring your child’s use of fluoridated toothpaste are key facts. Only place a pea-sized amount of toothpaste on your child’s toothbrush. Also teach your child to spit out the toothpaste after brushing instead of swallowing it. To encourage spitting, avoid toothpastes containing flavors that children may be likely to swallow. Adult supervision of tooth brushing by children younger than 6 years of age and changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.





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