Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Resident: Roberts

Date: 1/26/11

Author: Shabtai Sapir

Journal: Pediatric Dentistry

Volume: 29 Number: 4

Year: 2007

Title: Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Discussion

Developmental defects of enamel(DDE) consist mainly of hypoplasia and of diffuse demarcated opacities. Fluorosis, Amelogenesis imperfecta, and even dentinogenesis imperfecta may be considered developmental defects of the enamel. Often times a patient who presents with DDE will complain of poor esthetics, thermal sensitivity, attrition, secondary caries, tooth discoloration, malocclusion and periodontal problems. It is upto the clinician to take into account the patients chief complaint and whatever other complications may present with the condition and treatment accordingly for the best result possible.

Prevention

When possible preventative treatment can an important step in managing a patient with DDE. This consist of early detection, often noted at the early eruptive stages of the 6 year molars as well as along with the anterior incisors. When detected, oral hygiene instruction may include proper toothbrushes and techniques as well as desensitizing toothpaste if necessary. A weekly topical fluoride gel or varnish application and daily sodium fluoride rinse may improve resistance to demineralization, decrease tooth sensitivity, and enhance enamel remineralization as well as post eruptive maturation. The use of a sealant early on may be appropriate when possible. Mechanical preparation of the enamel prior to application is not desirable unless integrity of the enamel has already been compromised

Thoughts about which adhesive system to use

The shear bond strength of resin composite bonded to hypo-mineralized enamel is significantly lower than bonding to normal enamel. Phosphoric acid, most commonly used for enamel etching, may cause more enamel loss than self-etching primers, reducing the adhesion to hypo-mineralized enamel. Self-etching adhesives( which are hydrophilic, bond chemically and micro-mechanically) may offer an alternative that better meets the challenge of adhesion to hypo-mineralized enamel.

Treatment

Treatment depends on the severity of the condition. A definite correlation between color and porosity, mineral content, and depth has been established. Yellow-brown defects tend to be deeper extending all the way to DEJ. Whereas white creamy defects are usually less porous and variable in depth.

mild cases of hypoplasia and fluorosis

Usually no treatment is indicated unless small and minor lesions exist. If this is the case enamel micro-abrasion can be performed but caution must be taken to not remove to much of the surface area compromising the integrity of the rest of the tooth. Fluoride applications and bleaching can also have a positive effect with these cases.

moderate cases of hypoplasia and fluorosis

Micro-abrasion may be considered. When moderately significant tooth structure is removed then a composite restoration should be considered to restore form and function. Self-etching primers are not recommended in moderate and severe fluorosis, as they provide a lower shear bond strength.

severe cases of hypoplasia and fluorosis

Crown restorations with resin composites, polycarbonate crowns, laminate veneers, or porcelain crowns may be indicated in these circumstances. If severe DDE is suspected the earlier the treatment the better the prognosis. For lesions not associated with fluorosis, self etching primer is preferred. When the defects involve proximal surfaces RSC can be very retentive and esthetic, when posterior teeth are involved or the state of hypoplasia is so severe polycarbonate or cast crowns is preferred and has been proven to be more durable. With severe fluorosis and AI a pre-rinse with 5% NaOCL can improve the mechanical and chemical bonding of the adhesive for better results.

Treatment of DI

The primary dentition is usually affected more often than the permanent dentition. Intracoronal restorations and veneers may be considered for anterior teeth. External bleaching has a history of producing positive results. Most posterior teeth are severe and require early restoration with SSC’s. In the anterior dentition RSC may not have good results due to adhesive problems. Anterior permanent teeth that erupt should however be covered with composite until they fully erupt to avoid attrition and then have a RSC, polycarbonate crown placed until a PFM crown can be placed at a later date.

Conclusion

Early detection and preventative measures may go along way to maintaining the health of a compromised dentition. Educating the parents so that definitive action can take place will be necessary for a good long term prognosis.