Guideline on Pediatric Restorative Dentistry

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Guideline on Pediatric Restorative Dentistry.

Author(s): Clinical Affairs Committee.

Journal: AAPD Reference Manual.

Year. Volume (number). Page #’s: 2008. 32(6). 187-193.

Major topic: Restorative Dentistry

Overview of method of research: Clinical Guidelines.

Purpose:
To assist the practitioner in the restorative care of infants, children, adolescents and persons with special health care needs.

Methods:
Guideline is based on a review of current literature as well as best clinical practice and expert opinion.

Background:
When restoring the patient’s dentition, the treatment plan should take the following into consideration: developmental status of the dentition, caries risk assessment, the patient’s oral hygiene, anticipated parental compliance and the patient’s ability to cooperate for the procedure. Studies have shown that maxillary primary anterior decay has a direct relationship with primary molar caries. The primary dentition is also highly predictive of caries in the permanent dentition.

Recommendations:

Dentin/enamel adhesives:
Literature supports the use of bonding adhesives when used according to the instructions for that particular product. It shows similar effectiveness in enhancing the retention of restorations, reducing microleakage and sensitivity in primary and permanent dentition. Proper technique is critical for success.

Pit and fissure sealants:
1. Sealants should be placed based on the patient’s caries risk rather than age or time since eruption.
2. Sealants should be placed on high risk surfaces or surfaces that have already experienced incipient lesions. Sealants should be monitored and with proper maintenance have been shown to have 80-90% success rates at 10 years or longer.
3. Prior to sealant placement, proper cleaning of the pits and fissures should take place as should enamoplasty when indicated. Isolation is key.
4. A low-viscosity hydrophilic bonding material layer, either as part of the sealant or beneath it is recommended for long term effectiveness.
5. GIs can be used as a transitional sealant as they have shown a poor retention rate.

Glass ionomer cements:
GIs are useful in children because of their chemical bonding to enamel and dentin, biocompatibility, thermal expansion similar to that of tooth structure, uptake and release of fluoride and decreased moisture sensitivity compared to resin composites.
Recommended uses:
1. Luting cements
2. Cavity base and liner
3. Class I, II, III, and V lesions in primary teeth
4. Class III and V in permanent teeth with high caries risk or cannot isolate.
5. Caries control with high risk patients, restoration repair, interim therapeutic restorations (ITR) where traditional treatment must be postponed or caries control and alternative restorative technique (ART) which serves as a definitive restoration in populations who have limited access to dental care.

Resin-based composites:
Indications- Class I PRRs or caries extending into dentin, Class II restorations in primary teeth that do not extend beyond the proximal line angles, Class II restorations in permanent teeth that extent 1/3-1/2 buccal-lingual intercuspal width and Class III, IV and V as well as strip crowns in primary and permanent dentitions.
Contraindications- difficult isolation with no moisture control, large multi-surface posterior restorations in primary dentition and high-risk patients with multiple caries and poor oral hygiene and compliance.

Amalgam restoration indications:
“In children age 4 or younger, SSCs had a success rate twice that of amalgams.” Amalgams are adequate if enough tooth structure remains to withstand occlusal forces and the tooth is expected to exfoliate within 2 years.
1. Posterior class I and V restorations in primary or permanent teeth.
2. Posterior class II restorations that do not extend past proximal line angles in primary teeth.
3. Posterior class II restorations in permanent teeth.

Stainless steel crown restoration indications:
High-risk patients with anterior caries and or molar caries, extensive decay and multi-surface lesions in primary molars with “strong consideration” for those children treated under GA. SSCs have also been indicated in teeth that are used as space maintainers, when other restorative materials are likely to fail, when cooperation is affected. SSCs can also be used on anterior teeth, several veneered SSCs are available, but may be difficult to adapt and the facing is subject to loss or fracture.

Labial resin or porcelain veneer restoration indications:
Anterior teeth with fractures, developmental defects, intrinsic discoloration and/or other considerations. Porcelain veneers are usually placed on permanent teeth.

Full-cast or porcelain-fused-to-metal crown restoration indications:
Permanent teeth which are fully erupted and gingival margin is at the adult position with developmental defects, extensive loss of tooth structure whether from caries or trauma, completed endodontic treatment, as an abutment for a fixed prosthesis or single tooth implants.

Fixed prosthetic restorations for missing teeth:
Growth must be a consideration when using fixed prosthetic restorations in the developing dentition. They may be used to replace 1 or more teeth to establish esthetics, maintain arch space, to prevent harmful habits and improve function.

Removable prosthetic appliances:
May be used in the primary, transitional or permanent dentition to maintain space, obdurate congenital or acquired defects, provide esthetics, occlusal function or aid in speech development or feeding.

Assessment of Article:
I believe most of us follow these guidelines on a regular basis, but the article had some interesting points and clarified a few grey areas. Good review.