The use of amalgam in pediatric dentistry

Resident: Cho

Author(s): Fuks, Anna.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2002. 24. 448-455.

Major topic: Amalgam

Type of Article: Position Paper

Main Purpose: This report summarizes the several factors regarding amalgam restorations, including the material itself, the operator, and the patient.

Key points/Summary:

Factors related to the material:

- Toxicity of amalgam:

All estimates of daily total amalgam-associated mercury intakes are well below threshold for hazard to health. One human study demonstrated that the correlation between mercury levels in the mother and the newborn child was more closely related to the amount of fish consumed than to the number of amalgam fillings in the mother. True allergies to amalgam are rare, though there have been reports of an associated oral lichenoid lesion adjacent to amalgam restorations on rare occasion.

- Marginal integrity:

Amalgam is the only restoration nowadays in which the marginal seal improves with time. This is due to the acid environment and the low oxygen concentration in the space between the tooth and the restoration, leading to corrosion.

Factors related to the patient:

A disadvantage of amalgam is that it is unsuitable for minimal carious lesions. Studies have reported that the lifespan of SSC’s were twice that of amalgam for children age 4 years of age and younger. If the carious lesion is extensive and/or in more than 2 surfaces, a SSC would be indicated even for children older than 4 years of age.

Factors related to the operator:

Amalgam tends to be much less technique sensitive and more operator friendly compared to other restorative materials.

Recommendations for amalgam:

1. Class I restorations in primary and permanent teeth

2. Two surface Class II restorations where prep does not extend beyond proximal line angles

3. Class II restorations in permanent molars and premolars

4. Class V restorations in primary and permanent posterior teeth

Assessment of Article: Good summary of why amalgam is a great restoration!

Extent of Tooth Decay in the Mouth and Increased Need for Replacement of Dental Restorations: The New England Children’s Amalgam Trial (NECAT)

Resident: J. Hencler
Date: 12/08/2010

Article title: Extent of Tooth Decay in the Mouth and Increased Need for Replacement of Dental restorations: The New England Children’s Amalgam Trial (NECAT)

Author: Trachtenberg et al.
Journal: Pediatric Dentistry V30/No 5 Sept/Oct 08
Major topic: Factors contributing to restoration replacement

Main Purpose:
Investigate the association b/t the rate of restoration replacement and the number of dfs/dft and DFS/DFT at the time of restoration placement.

Overview of method of research:
Data was collected as part of the NECAT. Children b/w 6-10 years old were eligible if they had no existing amalgams and 2 or more posterior teeth w/ caries requiring occlusal restorations. 534 children were included in the study and randomized to receive either amalgam or composite/compomer restorations. Follow up was completed every 6 months for a five-year period. If a restoration required replacement, the reason was categorized as one of the following: 1) new caries; 2) recurrent caries; 3) fracture; 4) restoration loss; 5) other.

Findings:
Over the 5-year trial, 3,604 restorations with follow-up were placed in 489 children. Median dfs/DFS and dft/DFT were 15 and 8, respectively. Over the entire study, 212 of restorations required replacement due to new caries on adjacent tooth surfaces or recurrent caries. Of these, 69 were in primary teeth and 143 in permanent teeth.

Key points in the article discussion:
It is clear that the need for replacement increased with decay in the mouth. In terms of predicting the need for replacement, the number of dft/DFT rather than surfaces, was the better measure and found to be significantly related to replacement rates. Replacement rates were higher for increasing numbers of dft/DFT. The need for replacement also increased with age, was higher in posterior teeth compared to anterior teeth, and was significantly higher for composite and compomer restorations than amalgam. This paper presents for the first time analyses to investigate the increasing need for restoration replacement due to decay in the mouth. Although this association has been common knowledge among dental practitioners, there have been no prior studies to substantiate this consensus, nor any data to provide info to dentists and patients about the likelihood of replacement. Parents should be informed that dental restorations are susceptible to failure and that this failure may be preventable in the same way that tooth decay is preventable with modifications in OH and diet.

Summary of conclusions:
Children w/ high rates of caries are at higher risk for replacement of restorations. Patients should be informed that dental restorations are susceptible to failure due to factors related to tooth decay such as bacteria, diet, and poor OH.

Assessment of article: Good study.
It quantified what we already know; that high caries risk is related to increased restoration replacement.

Long-term Photographic and Radiographic Assessment of Bonded Resin Composite Strip Crowns for Primary Incisors: Results After 3 Years

Resident: Roberts

Date: 12/8/10

Article title: Long-term Photographic and Radiographic Assessment of Bonded Resin Composite Strip Crowns for Primary Incisors: Results After 3 Years

Author: Kupietzky, Ari

Journal: Pediatric Dentistry

Volume: 27: 3

Year: 2005

Purpose

The aim of this study was to examine the photographic and radiographic success of the treatment fo maxillary anterior primary incisors with composite resin strip crowns placed in a private-practice setting after a minimum of 18 months.

Methods and Results: 145 restorations, placed in 52 children, were evaluated by two independent pediatric dentist. Radiographs and photographs were used to evaluate the results. The average time of evaluation was 31.3 months after initial placement of the resin crown. None of the restorations were totally lost. 20% of the restoration showed some form of lost resin material, resulting in an overall 80% retention rate. 92% of teeth indicated healthy pulps, 6% had signs of change but did not require immediate attention( changes noted included: prematrure resorption, calcific metamorphosis and internal resorption) Only 2 teeth showed signs of radiographic evidence of pulpal pathology that required immediate treatment.

Conclusion:

Strip crowns are an excellent choice for teeth that present with multisurface caries. The long term prognosis has a high degree of predictibility and esthetics are unparallelled by other similar restorations. With these results, clinicians should be more apt to choose strip crowns over some of the other more expensive and less esthetic options.

Clinical Evaluation of a Compomer and an Amalgam in Primary Teeth C lass II Restorations: A 2 year Comparative Study

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Clinical Evaluation of a Compomer and an Amalgam in Primary Teeth C lass II Restorations: A 2 year Comparative Study
Author(s): Katerina Kavvadia, DDS, MDent Sc, Dr Odont. Et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. Vol 26 no 3. 245-251
Major topic: The purpose of this study was to compare the clinical performance between the compomer f2000 and amalgam Dispersalloy in class II restorations in primary molars over a 2 year period.

Overview of method of research: 75 amalgam and 75 comps were placed in 75 children in two separate pediatric dentistry private practices. In each child, an amalgam and a composite were placed in contra-lateral sides. The restorations were evaluated at 1 week, and then 6, 12, and 24 months by two independent calibrated evaluators. The rests were evaluated clinically, radiographically (bitewings), and under scanning electron microscope. The clinical exams were performed according to the Ryge criteria, including
1. Retention, bulk fracture, and presence (or not) of secondary caries. Ranked as either Yes or NO
2. Surface texture, marginal adaptation, marginal discoloration, contact area, and anatomic form. Ranked as either Alpha (ideal), Bravo (Acceptable) or Charlie (Unacceptable).

Findings:
Clinically
One amalgam was lost, and one comp had secondary caries. No bulk fractures in either group. None graded as “Charlie”. Many comps. Were rated as “Bravo”, while many Amals. Were rated as “Alpha”.

Radiographically
Five Amals and four Comps had cervical defects. These defects did not progress after 24 months.

SEM
Amals demonstrated marginal microfractures leading to ditching, leading to loss of anatomic form. Comps exhibited generalized wear, leading to loss of anatomic form and exposure of the cavity walls (although no marginal integrity was lost).

Key points/Summary:
Eventhough comps exhibited significantly higher “Bravo” scores regarding marginal adaptation and anatomic form, there is not an increased risk for secondary caries and failures… over a 2 year period!

Assessment of Article: Good article, Skeptical about how they continually reviewd how amazing the results were, and how awesome the comps were, but then quietly mentioned it was only with regards to the 2 year time frame. Shenanigans? Maybe.

Effect of Adhesive Systems and Bevel on Enamel Margin Integrity in Primary and Permanent Teeth

Resident: Adam J. Bottrill
Date: 17NOV10
Region: Providence
Article title: Effect of Adhesive Systems and Bevel on Enamel Margin Integrity in Primary and Permanent Teeth
Author(s): Swanson T.K. et al.
Journal: Pediatric Dentistry
Page #s: 134-140
Date: V30/No2 Mar/Apr 08
Major topic: Marginal Integrity, Enamel Beveling, Self Etching
Minor topic(s): NA
Type of Article: In vitro, factorial-designed study
Main Purpose: The study compared the effectiveness of self-etch and total-etch adhesive systems in bonding to the beveled and nonbeveled margins of primary and permanent teeth.
Key points in the article discussion:

I. General:

A. Bonded interfaces are NOT perfect and confidence in their long-term durability is not complete.
B. "Self-etching" adhesives are being ADVERTISED as less technique sensitive, less time consuming yet just as effective as total-etch adhesives.
C. Three total steps... ETCH, PRIMER, ADHESIVE
D. Recent studies have shown there is no difference with current self-etch materials and whether or not the preparation is beveled.

II. Methods:

A. 3 Factors: tooth type, presence of a bevel, adhesive type
B. 2 preparations (beveled and non-beveled) completed on B surfaces of 60 extracted molars (30 primary, 30 permanent)
C. Randomely assigned self-etech vs total etch
D. Thermocycling.... staining.... sectioned.... measured for microleakage.


III. Results:

A. Beveled margins had less microleakage for both types of teeth.
B. Total-etch had less microleakage than self-etch adhesives. (53% primary 22% permanent !!!)
C. Self-etch had considerably more leakage on non-beveled preps
D. Comparably less microleakage for both types of etch on beveled margins.

IV. Conclustions:

A. Total etch AND beveled margins result in less leakage.
B. Beveling has greater effect on minimizing microleakage than type of adhesive.

Assessment of article: SHENANIGANS.
A. This should have been three studies. Not one... in my opinion.
B. With the self-etch method they used two coats.... WHAT'S THE POINT.
C. I rarely appreciate in vitro studies that attempt to mimic actual patient/clinical conditions.
D. Thermocycling? 131 degrees to 41 degrees? 500 times? Silver nitrate immersion?... come on man. That may be the closest they can achieve to actual conditions... still not the same as a mouth.

Clinical Outcomes for Primary Anterior Teeth Treated with Preveneered Stainless Steel Crowns

Resident’s Name: Ara Cho

Author(s): MacLean, JK et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2007. 29. 377-381.

Type of article: Retrospective Study.

Major topic: Anterior Primary Teeth, Early Childhood Caries, NuSmile Crowns

Purpose: To determine the clinical outcomes for a sample of NuSmile crowns used to treat anterior teeth with early childhood caries.

Overview of method of research:

Patients of either a private pediatric dentist or public health clinic and had NuSmile crowns were selected for the study. First- or second- year pediatric dental residents or a dentist in private practice placed the NuSmile crowns. The crowns were placed by 10 clinicians total. The children were evaluated at a followup appointment and three nonblinded, calibrated examiners evaluated the crowns. The parent or guardian completed a written survey to assess parental satisfaction.

Findings:

A total of 226 NuSmile crowns were evaluated in 46 patients. Mean age of crown placement was 4 years of age. Mean time of evaluation was 13 months after placement of the crowns. Each patient had an average of 5 crowns. 91% of the patients were treated under G.A., 4% with nitrous oxide, 2% with oral conscious, 2% with behavior management. 96% had positive behavior and 4% had negative behavior. 24% of patients had history of bruxism and 28% of patients had history of trauma to the crowned teeth.

91% of all patients maintained a good to excellent overall appearance after at least 6 months. NuSmile crowns are a clinically successful complete coverage restoration for anterior primary teeth as evidenced by: 86% resistance to fracture, 71% resistance to attrition, 99% retention, 99% resistance to crazing, and 99% color stability over a minimum of 6 months.

When comparing shade of the NuSmile crown to the natural teeth, only 2 patient’s shades matched. The NuSmile crown was lighter in 88% of the patients.

Key points/Summary:

1. NuSmile crowns are a clinically successful restoration for anterior primary teeth.
2. Despite some negative clinical changes, 91% of NuSmile crowns retain a good to excellent overall appearance after 6 months.
3. Canine NuSmile crowns are the least clinically successful. They are most likely to fracture, wear, and appear bulky.
4. There is an increased incidence of attrition with increased time and with bulky crowns.
5. Successful results with NuSmile crowns may be obtained by both the experienced operator and the novice.

Assessment of Article:

This article highlights the advantages of NuSmile crowns, however, does not really address the esthetic concerns of the crown. The fact that only 2 patient’s shades matched is quite significant. Only 37% of patients had excellent overall appearance; 50% had good overall appearance.

The Use of Stainless Steel Crowns

Resident: Swan

Article Title: The Use of Stainless Steel Crowns

Author: N. Sue Seale

Journal: Pediatric Dentistry

Volume (Number): 24:5 2002

Major Topic: A discussion of the indications for and efficacy of stainless steel crowns for primary molars

Main Purpose: Discuss both clear-cut and not so clear-cut instances where an SSC would be a good treatment option

Type of Article: Position Paper

Main Points of Discussion:

--Advantages of Stainless steel Crowns: Extremely durable, relatively inexpensive, minimal technique sensitivity, offers full coronal coverage.

--Main Disadvantage: Esthetics

--Clear cut applications: following pulpectomy/pulpotomy, and in teeth with developmental defects, large multisurface carious lesions, or fractures.

--Where it becomes more difficult: In treating lesions small enough to allow other restorative options. We need to consider caries risk, restoration longevity, and cost effectiveness

Caries Risk: Study cited that reported 8X increase in buccal/lingual/approximal caries over a two year period in 3 year olds with decay on the maxillary anterior teeth. Another study reported that 57% of children with proximal molar carious lesions in the primary dentition developed additional interproximal primary molar lesions in the mixed dentition. Conclusion: kids develop predictable caries patterns over time.

“High Risk” Indicators: dmfs greater than child’s age, 2 or more new carious lesions in 1 year, numerous white spot lesions, high S. Mutans counts, low socioeconomic status, relatives with high caries rates, appliances in mouth, and history of sugary diet. Also consider ability to recall child on a regular basis.

**With high risk patients, more aggressive treatment with SSCs is better over time

Restoration Longevity: Studies have documented the superior durability and life span of SSCs over class II amalgams. Study by Randall: In 5 published sets of data with average follow up time of 5 years, amalgam failures rate was 2 to 7 times more than that of SSCs.

-Studies show amalgam life expectancy to be approx. 2 years. When restoration needs to last more than 2 years, according to this author, best practice would be to chose an SSC in multisurface restorations of molars. Also, SSCs can be placed with little compromise in a difficult child, where moisture control is unrealistic.

Cost Effectiveness: Randall found 3 studies that examined the cost effectiveness of SSCs vs. amalgams. Two reported the SSC was more cost effective, one reported SSC to be more expensive over time (last study included both Cl I and Cl II amalgams). In studies, most common failure for SSCs is when crown falls off (can often re-cement same crown,= less cost, whereas replacement for a failed amalgam is often an SSC,=more cost). SSCs are recommended for children who require tx under GA=more cost effective, likely we’ll see them in the OR less often.

Summary and Assessment: SSCs are durable, long-lasting restorations that outperform Cl. II amalgams across the board. While there are several clear cut situations that call for their use, oftentimes we need to judge for ourselves. When making tx decisions and discussing with parents, we should consider caries risk, restoration longevity, and cost effectiveness. I liked this article because it succinctly summarized what should be going on in our minds when we are making these types of treatment decisions.