Wednesday, August 29, 2012

Children With Severe Early Childhood Caries: Pilot Study Examining Mutans Streptococci Genotypic Strains After Full-mouth Caries Restorative Therapy

Resident: Matthew Freitas
Author: Palmer, Elizabeth DMD
Journal: Pediatric Dentistry V34/NO2 MAR/APR 2012

The purpose of this pilot study was to examine the profiles of mutans streptococci (MS) strains and non-MS bacteria from pediatric patients who exhibit severe ECC.

Mutans streptococci represents the most predominant microorganisms associated with dental caries and consists of 7 species; with Strep mutans most frequently isolated. Strep mutans has been further classified into 4 sterotypes- c, e, f, and k. Strep mutans "c" is most commonly isolated (70-80%).

-Study was conducted in Portland, Oregon.
-Children were between 3-5 years of age with no NSMF and severe ECC. Treatment was completed in the OR under GA.
-Any child who used an antibiotic, fluoride mouthrinse or varnish, and/or oral antiseptic within the previous 3 months were excluded.
-Plaque samples were obtained at 3 time points: 1. prior to surgery, 2. Two-four weeks post op, and 3. Six month recall visit.
-They used a sterile swab that was brushed along the buccal and lingual surfaces of the entire dentition.
-The samples were then sent to the lab.

-9 patients enrolled, 7 patients available at 2-4 week recall, and only 5 available at 6 month recall.
-They found 39 genotypic strains of Strep mutans and 7 genotypic strains of non-MS.
-3-7 strains of Strep mutans were isolated for each patient prior to treatment. Recall samples showed that all diminished to only 1-2 dominant strains.
-They concluded that restorative therapy resulted in a decreasing shift in the distribution of MS strains.

I thought this was an interesting study, but a tough read with a lot of scientific data. One thing they noted prior to initiating restorative treatment in the OR, was that they cleansed the entire dentition and oral tissues with Chlorhexidine. This study is a pilot study to aid in exploring the genetic diversity of Strep mutans and it's role in caries disease. Recent studies suggest that the cumulative effects of many different MS genotypes in a single patient may increase risk of dental caries.

Examination, Diagnosis, and treatment planning of the Infant and Toddler

Pinkham et al Chapter 13
Infant oral health-
  • First visit to the dentist traditionally was set up around the time the child started school or as needed due to trauma or other problems
  • In 1986 the AAPD changed its recommendations for children to be seen within 6 months of the eruption of the first tooth or one year.  This was done to bring dentists into the health care team as often times MDs are unfamiliar with dental problems.
  • There is still reluctance from some dentists to see small children because of lack of training to deal with young children and uncooperative behavior. 
Goals of Infant Oral Health
  1. Break the cycle of ECC-Seeing chidren from an early age can help help to intervene to prevent decay.  Interestingly, it remains to be demonstrated if early intervention acutally does prevent decay, it is hard to ignore the population of caries free children who have seen a dentist regularly. 
  2. Disrupt the acquistion of harmful microflora-Prevention of vertical transmission of cariogenic bacteria, primarily from mother, is a goal of early intervention. 
  3. Manage risks/benefits of habits-Discuss with parents the use of pacifiers and the appropriate times when habits should be stopped and reasons why they are not recommended.
  4. Establish a dental home for health and harm-Care is begun with nonthreatening preventive services then if emergency visits are needed then the setting is familiar.  Likewise, the family has a resource to consult with questions or problems
  5. Impart optimal fluoride protection-Fluoride remains the primary tool for prevention of caries with prevention of fluorosis also a role teh dentist can play,
  6. Use anticipatory guidance to arm parents in the therapeutic alliance-Make parents a co-provider in the care of their child's teeth so they can influence the child's diet at home or school. 
Concepts of Infant Oral Health
  • Risk Assesment-Assesing risk for dental disease based on detailed history of oral habits and diet also taking into account environmental conditions and general health conditions.
  • Anticipatory Guidance-Proactive counseling of parents and patients about developmental changes that are going to occur and information about daily caretaking for the upcoming interval.  For example, warn parents of toddlers about tooth trauma following newly acquired walking and crawling skills. 
  • Health Supervision-Regular preventive and therapeutic care is more beneficial than episodic and fragmented care.  Recall schedules may be recommended at short or longer intervals based on each patient's specifric circumstances.  It is important to have measureable goals to measure outcomes (no gingival bleeding, no plaque, etc.)
Infant Oral Health as a Diagnostic Process
  • Infant oral health should be approached the same way that that diagnosis of disease is approached.  Although a chief complain may be absent from many visits,  the process should still contain a detailed history,  exam, and differentail diagnosis.  If no needs are present, then instead of treatment plan the family receives anticipatory guidance for prevention fo future problems. 
Elements of the Infalt Oral Health Visit
  • Risk assesment-History taken and analyzed including health history, diet, fluoride use, oral habits, injury prevention, development, and hygiene.  These factors are combined to determine risk levels and appropriate monitoring regiment.
  • Oral Examination and Assesment of Clinical risk factors-K2K exam is the desired method.  A dental chair is not needed and not preferred.  Parents should be warned that children will likely cry during exam and that crying is the normal response and acutlly is desired to get a good view of the teeth.  Infants will generally have a healthy mouth but inspection for abnormalities is important.
  • Risk Profiling-Once a risk level has been determined,  parents should be given an explanation of the process and what factors were used in the decision and an estimate of the influence a particular factor is having.
  • Anticipatory guidance-Make parents aware of upcoming milestones and give recommendations accordingly (pacifier and bottle use, sippy cup, feeding etc.)
Growth and Development Treatment Planning
Non-nutritive sucking habits-Prolonged habits can lead to orthodontic problems such as open bite and constricted arch.  Dentists often become involved when intervention is required.  Understading the process of the habits can help with prevention of such problems as well as proper treatment planning.
  • Origins of sucking habit-Most commonly accepted theory is the learning theory which states that sucking is an adaptive habit which is often a reward and becomese a learned habit.  Prolong digit or pacificer use beyond preschool years can reflect psychological disturbance most notably failure to learn coping skills.
  • Prevalence of sucking habits-Prevalance is very high.  90% of peole had a sucking habit at one time.  Generally children stop between 2 and 3 years of age.  Kindergarten attendance is a big influence as peer pressure from other children generally stops the habit.  If possible, pacifier should be used instead of fingers as the orthodontic forces are more favorable and the mental impact of using a pacifier can be helpful as motivation for stopping. 
  • Effects and mechanism of nonnutritive sucking habits of the dentition-Orthodontic forces can cause open bite, constriction of upper jaw, class II relationship, and signifcant amounts of overjet.  Open bites generally self-correct with cessation of habit but other malocclusions require orthodontic treatment
  • Recommendations-Elimination of habits should be completed by 24 months.  Due to the fact that digit habits are more damaging than pacifiers, pacifiers should be substituted for fingers if possible.  Elmination of habits before one year of life is not advised due to psychological and physiologic need for sucking. 
Office Readiness for Intant Oral Health
  • Traditional prophy equipment is not needed for infants.  Training of staff for age appropraite set up and equipment will help to improve efficency and provide for a better patient experience.

Tuesday, August 28, 2012

AAPD Handbook ch. 1 Infant Oral Health

Resident:  Jeff Higbee

AAPD – The Handbook of Pediatric Dentistry, Ch. 1 Infant Oral Health


Professional strategies within 6 months after the eruption of the 1st primary tooth or no later than one year directed at factors affecting the oral cavity, oral disease risk, and delivery of anticipatory guidance.

Early intervention or mitigation of common pediatric oral diseases and conditions.  Initiating a relationship between infant, child, family and pediatric dental caregiver.

Primary prevention of dental disease by use of education, behavioral changes, fluoride management, identification of risk, and tailored preventative programs.

Foundation upon which prevention of oral injuries, management of oral habits, assessment of oral development, and consideration of individual needs to enhance a child’s opportunity for a lifetime free from preventable oral disease.


Early oral exam along with oral health risk assessment and anticipatory guidance are effective means of true primary prevention.  Early Identification and management of oral health issues are cost effective and lead to satisfactory outcomes.



-Timely delivery of family education on caries process, appropriate oral hygiene practices and feeding/dietary habits for caries prevention.  Ultimate goal is to avoid surgical intervention.

-Timely consideration of fluoride management and preventative strategies.

-Provide anticipatory guidance and identify high risk children for ECC at an early age.  Identify high risk mother during pregnancy.

-Establish a dental home by age 1.

Steps Involved in Infant Oral Health Care:

-Detailed medical and dental hx

-Clinical eval of oral structures (knee to knee).

-Counsel about caries risk factors and provide anticipatory guidance in the area of dental and oral development, fluoride, teething, oral habits, injury prevention, dietary and oral hygiene instruction.

-Counsel about bacteria transmissibility.

-Assess the infant’s caries risk using AAPD Caries-Risk Assessment.

-Decide on supplemental procedures which may include caries risk testing, selected radiographic exam, water fluoride analysis, consultation with other dental and medical providers.

-Follow-up procedures are those indicated in the “Guideline of Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children”.

Anticipatory Guidance:

Parents are given counseling in infant oral hygiene, home and office based fluoride therapies, dietary counseling, and information relative to oral habits and dental injury prevention.  It is important to counsel parents about oral developmental changes that may occur between their children’s dental visits.  It is also important to prepare parents for future age-specific needs and dental milestones.

                Topics for discussion for parents with children between ages birth to 3yrs

-Dental and oral development

-Fluoride supplementation

-Non-nutritive habits

-Injury prevention


-Oral Hygiene

Oral Health Risk Assessment:

Systematic evaluation of the presence and intensity of etiologic and contributory caries risk factors designed to provide a disease susceptibility estimation and help in determining preventative and treatment strategies.

                What to address…

-Medical Hx

-Oral Hygiene

-Infant feeding

-Dietary Habits

-Fluoride Adequacy

-Bacteria Transmission

-Demographic Data

-Teeth Characteristics

-Iatrogenic factors

-Salivary Assays for MS


Caries Risk Assessment Form 0-5 yrs

High Risk Factors

-Mother/primary caregiver caries                                                                                            

-Low socioeconomic status

-More than 3 between meal sugar snacks or drink

-Bed with bottle containing sugary drink

-Less than 1 dmfs

-Active white spot lesion or enamel defect

-Elevated MS levels

                Moderate Risk Factors

-Special health care needs

-Recent immigrant

-Plaque teeth

Protective Factors

-Optimal fluoride water or supplementation

-Daily brushing with fluoridated tooth paste

-Professional topical fluoride

-Established dental home and regular care

Early Childhood Caries Screening Tools: A Comparison of Four Approaches

Kyung-Hong Cal Kim

Early Childhood Caries Screening Tools: A Comparison of Four Approaches

Authors: Yoon RK, Smaldone AM, Edelstein BL

JADA July 2012

To evaluate the accuracy and clinical usefulness of existing screening tools (CAT w/o MS, CAT w/o SES or MS, the CAT w/o SES but with MS and MS alone) that have been developed to identify young children according to S-ECC risk and status.

-CAT form
*Child’s general health
*Intake of medicines
*Between-meal sugar exposure
*Maternal caries activity
*Topical fluoride exposure
*Caregivers’ SES

-Intraoral exam
*Visible plaque
*Evidence of decalcifications and caries

-MS level assessment
*Sterile tongue depressor onto the dorsal surface of the patient’s tongue impressed onto MS-selective agar medium

-Strongest risk factors in the CAT (w/o MS screening) were gingivitis or visible plaque, between-meal sugar exposures, recent maternal caries experience and suboptimal fluoride exposure
-MS assessment alone had the highest overall sensitivity, specificity, and predictive value of all factors

Assessment of the article:
I thought it was an interesting article but it was also confusing at the same time, possibly because there were so many varying factors and limitations that could affect the study. One of the few things that I got out of this article was that although low socioeconomic status can be an important contributing factor for ECC (or S-ECC) but children from family with low SES are not necessarily doomed or children from affluent families are not necessarily immune to ECC (or S-ECC), which we already knew from our own experience. Correlation between socioeconomic status and caries pattern in children, I believe, is not as strong as it used to be, because while it is true that foods that are more affordable generally have higher sugar (high fructose) contents, but frequent exposure to sugar is no longer out of necessity by families of low SES but more due to recent change of parenting philosophy.

Guidelines on Adolescent Oral Health and Guidelines on Role of Dental Prophylaxis in Pediatric Dentistry

Todd Bushman

Article Title: Guideline on Adolescent Oral Health Care

Authors: Clinical Affairs Committee; Council on Clinical Affairs, Committee on the Adolescent

Journal: Pediatric Dentistry Reference Manual

Volume (number), Year, Page #’s; V32/NO 6 10/11, 119-126

Major Topic: Guidelines addressing the special needs of the adolescent population.

Findings: Adolescence is defined as youths between the ages of 10-18. This population of patients is recognized as having special needs for the following reasons:
1) high caries rate
2) increased risk for traumatic injury and periodontal disease
3) poor nutritional habits
4) increased esthetic desire and awareness
5) complex orthodontic and restorative care
6) dental phobia
7) potential use of tobacco, drugs and alcohol
8) pregnancy
9) eating disorders
10) social and psychological needs

Caries rate remains highest during adolescence due to immature permanent tooth enamel, an increase in susceptible tooth surfaces, poor diet, avoidance of care, low priority for oral hygiene and social factors.
Management: Primary prevention

Fluoride dependent on risk assessment.
·      Brush 2x daily
·      Topical fluoride based on CRA
·      prescription based on CRA
·      Systemic fluoride or supplements
Oral Hygiene:
Adolescence can be high risk for caries because of increased sugary foods and poor oral hygiene:
·      Adolescents need education and motivation
·      Professional monitoring and cleanings

Diet: Adolescents tend to consume high quantities on refined carbohydrates and cariogenic beverages. Recommendations:
·      Diet monitoring and management
·      Sealants if possible

Secondary Prevention

Preservation of tooth structure while completely treating the decay

Irreversible tissue damage from periodontal disease may begin in late adolescence.

Acute conditions:
Conditions such as ANUG and periodontitis

Chronic conditions:
Gingivitis, puberty gingivitis, hyperplastic gingivitis, hyperplastic gingivitis related to ortho, gingival recession, drug-related gingivitis, pregnancy gingivitis, localized juvenile periodontitis and periodontitis.

Recommendations for this population include:
1) Education
2) Age appropriate oral hygiene program
3) perio charting and radiographs
4) frenectomy, tooth ext, fiberotomy...


May include malposition of teeth, malrelationship of teeth to jaws, tooth/jaw size discrepancy or disfigurement that prevents function, esthetics, etc.

Third molars:
Third molars can cause acute and chronic conditions and should be removed if there is a high likelihood they will become a problem before the 3rd decasde

TMJ problems:
Evaluation and examination of this joint should be a part of every recall. TMD appears more prevalent during adolescence.

Congenitally missing teeth:
Management should include both immediate and long term treatment based on age, esthetics, growth potential, perio and oral surgical needs.

Ectopic eruption:
We must be proactive in the management of ectopic eruption. Prevention may include extraction of deciduous teeth, surgery, endo, perio, etc.

Recommendation and fabrication of a sport specific mouth guard should be initiated.

Additional considerations:

Discolored or stained teeth:
Judicious use of bleaching may be considered based on a comprehensive diagnosis.

Education and counseling should be provided. Associated pathology should be monitored.

Positive youth development:
Psychological and social needs are important. A strong interpersonal relationship between the adolescent and the dentist can be help in improving the patient’s oral health and transitioning to adult care.

Dentists must be aware of the behavioral considerations including anxiety, phobia and intellectual dysfunction. Consent, confidentiality and compliance should be addressed and a complete oral health care program is required.

Transitioning to adult care:
Educating the patient and parent on the value of transitioning to a dentist who is knowledgeable in adult oral health is important.

Guidelines on the role of Dental Prophylaxis in Pediatric dentistry

Authors: Clinical Affairs Committee; Council on Clinical Affairs, Committee on the Adolescent

Journal: Pediatric Dentistry Reference Manual

Volume (number), Year, Page #’s; V32/NO 6 10/11, 151-152

Main Purpose: Provide a guideline for dental prophylaxis along with periodic infant oral health assessment.

Key points in the article discussion:

I. General:

A. Microbial plaque is the primary etiological factor in caries and periodontal disease. This can be done at home but pts are usually deficient.

B. Indications:
1. Removal of plaque, stain, and calculus.
2. Elimination of factors that influence the build-up and retention of plaque.
3. Demonstration of proper oral hygiene methods to the pt/caregiver.
4. Facilitation of a thorough clinical exam.
5. Introduction of dental procedures to the child.

C. Type and frequency varies based on individual risk-assessment:
1. Medical Hx.
2. Age and cooperation.
3. Compliance.
4. Past and current caries.
5. Family Hx of caries.
6. Past and current perio health.
7. Family Hx of perio health.
8. Oral health.
9. Plaque.
10. Calculus.
11. Staining.
12. Local factors that would influence the build-up and retention of plaque.

D. Prophy can be performed with Toothbrush, rubber cup, floss, instruments.
1. Toothbrush ok if no stain or calculus.
2. Rubber cup prophy for extrinsic staining and smoothing edges after scaling.
3. Rubber cup with pumice may be used before fluoride.
4. Abrasive toothpastes and pumice may increase chances of enamel loss.
5. Pumice may remove up to 0.6-4.0 microns of outer enamel (includes the Fl-rich layer).

II. Recommendations:

A. Periodic Prophy should be performed to:
1. Instruct.
2. Remove plaque and calculus.
3. Polish hard surfaces.
4. Remove staining.
5. Facilitate the exam.
6. Introduce dental procedures to young children and apprehensive patients.

B. Practitioner should choose the least aggressive technique that fulfills the goals of the procedure. Least abrasive paste with light pressure.

C. If pumice or course past is used, Fl application indicated.

D. Patients at higher risk should have prophy at more frequent interval than 6 months.
1. Allows for OH monitoring and frequent Tx.

E. Individualized Tx plans are necessary.

Early Childhood Caries

Resident: Mackenzie Craik

Article #1: Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies.

Journal: American Academy of Pediatric Dentistry Reference Manual

Purpose: To recognize early childhood caries (ECC) as a significant public health problem and to encourage healthcare providers to implement preventive practices.

Key Points: 
-In 1978 the AAPD called ECC “Nursing Bottle Caries” as it was understood that it was associated bottle usage.
-They thought it could be eliminated if bottle usage was terminated after the age    of one.
-Over the next 20 years the AAPD recognized that it wasn’t only associated with poor feeding habits, but that caries was an infectious disease.  So it became termed Early Childhood Caries.
-ECC = The presence of 1 or more decayed, missing (due to caries), or filled primary tooth in a child under the age of 6.
-Severe Early Childhood Caries (S-ECC) = Any smooth surface decay in a child under 3.
-S-ECC = From ages 3-5, 1 or more cavitated, missing (due to caries), or restored tooth in the maxillary anterior.
-S-ECC =  Decayed, missing, filled score of:
-Greater than or equal to 4 if age 3
-Greater than or equal to 5 if age 4
-Greater than or equal to 6 if age 5
-Vertical and Horizontal transmission are the most common routes of infection.
-Eliminate saliva sharing activities to decrease the transmission.
-Newly erupted teeth may be at higher risk for developing caries due to immature enamel.
-Children under age 2 = smear of fluoridated toothpaste
-Children 2-5 = pea size amount of fluoridated toothpaste.
-High frequency consumption of sugar is an associated risk factor.
-AAPD recommends children 1-6 years of age consume no more than 4-6 oz/day.
-Access to care.

Article #2: Policy on Early Childhood Caries (ECC): Unique Challenges and Treatment Options

Journal: American Academy of Pediatric Dentistry Reference Manual

Purpose: To educated the health community and society about the unique challenges and treatment options of this disease, including the need for advanced preventive, restorative, and behavioral guidance techniques.

Key Points: 
-ECC in the U.S. and other countries is largely untreated in children 3 years old or younger.
-ECC is aggressive, if untreated:
-Areas of demineralization can lead to cavitation.
-If cavitated lesions are not treated they can lead to pulpal infections.
-Pulpal infections can spread to include life threatening facial space involvement.
-Prevention of ECC begins during prenatal and peri-natal periods.  Mothers should optimize nutrition during pregnancy and during infant’s 1st year  while enamel is forming.
-Mutans Streptococci (MS) which is most associated with ECC is usually transmitted vertically from mother to child, or horizontally from sibling to child.
-When associating the health benefit to risk of using fluoride, the key issue is mild fluorosis versus preventing devastating dental disease.  
-Interim Therapeutic Restorations (ITR), like glass ionomers that release fluoride are effective because the are both preventive and therapeutic.
-SSC’s are less likely than other restorations to require re-treatment.  
-To perform treatment safely, effectively, and efficiently, the practitioner caring for a child with ECC must often  employ advanced behavior techniques.  
-Protective stabilization 
-General Anesthesia
-Non-Dental health care providers who identify ECC should either provide therapy or refer patient to a licensed dentist.

Monday, August 27, 2012

Infant Oral Health Care: Beliefs and Practices of American Academy of Pediatric Dentistry Members

Resident: Derek Nobrega

Title: Infant Oral Health Care: Beliefs and Practices of American Academy of Pediatric Dentistry Members
Authors: Shikha Bubna, DDS, Silvia Perez-Spiess, DDS, Julie Cernigliaro, DMD, Kell Julliard, MA
Journal: Pediatric Dentistry. 2012. May-June 34(3) 203-209

Main Purpose: To survey AAPD members about their beliefs on the one-year-old dental visit and prenatal dental counseling.

Methods: 1500 AAPD dentists were sent a survey containing questions consisting of 3 main areas: demographics, infant oral evaluations, and prenatal dental counseling. For infant oral evaluations, respondents were asked whether or not they agreed with the AAPD “Policy on the Dental Home” and whether or not they performed age one dental visits. They were then asked whether or not they performed prenatal dental counseling to expectant mothers. 554 were returned, yielding approximately a 37% response rate.

Key Points:
1. 91% of respondents agreed with the AAPD Policy on the Dental Home, and 90% of respondents performed infant oral evaluations in their office.
2. The most frequently cited reasons for not performing age 1 evaluations were parents do not see the value (62%), existing conditions should dictate evaluation time (35%), low caries rate (29%), and too busy with older patients (20%).
3. Only 47% of respondents thought that an asymptomatic child should have his/her first oral evaluation by 12-months-old.
4. Most respondents who agreed with the policy were 50-years-old or younger, while most respondents who disagreed with the policy were 51-years old or older. 
5. Respondents practicing over 21 years were more likely to disagree with the policy statement than any other group and denied performing infant oral evaluations in their office.
6. 60% of parents interviewed were unaware that the inappropriate use of a baby bottle could result in harm to their child’s developing dentition.
7. Only 15% of practitioners provided prenatal dental counseling.

Assessment: Good survey showing the attitudes of currently practicing dentists. The results are interesting, indicating younger dentists are performing infant oral exams more often than older dentists. If nothing else, the one-year exam educates parents in topics they would otherwise not know. By simply educating parents of infants and expecting mothers, we can hopefully limit the amount of early childhood caries we see.  

Wednesday, August 22, 2012

Pediatric and General Dentists' Attitudes toward Pulp Therapy for Primary Teeth

Resident: Matthew Freitas
Author: J. Lucas Bowen
Journal: Pediatric Dentistry, V34/NO3 May/Jun 2012

Purpose: The survey assessed and compared the attitudes of pediatric and general dentists regarding treatment planning of indirect pulp therapy (IPT) in primary teeth.

-Electronic survey (SurveyMonkey) sent to 3,883 general dentists and 3,691 pediatric dentists nation wide.
-They were provided cases with radiographs where IPT would be appropriate for vital pulp therapy.
-Case 1: 4 year old with asymptomatic primary maxillary first molar with deep caries approaching the pulp, which would result in pulp exposure upon complete caries removal.
-Case 2: 5 year old with elicited pain upon eating or drinking on primary mandibular second molar with deep decay, which would result in pulp exposure upon complete caries removal.
-Case 3: 5 year old with spontaneous pain on primary maxillary second molar with deep decay, which would result in pulp exposure upon complete caries removal.

-1,259 (17%) surveys were completed.
-Case 1: Pediatric- 65% Pulpotomy and 28% IPT. General Dentist- 45% pulpotomy and 41% IPT.
-Case 2: Pediatric- 81% Pulpotomy and 8% IPT. General Dentist- 65% pulpotomy and 14% IPT.
-Case 3: Pediatric- 40% Pulpotomy, 1% IPT, 39% Pulpectomy, 20% Extract. General Dentist- 53% Pulpotomy, 3% IPT, 28% Pulpectomy, 16% Extract
-The article concluded that most providers are not regularly treating teeth with IPT because pulpotomy is believed to be more successful. And pediatric dentist are less likely to do so compared to general dentist.

-I thought this was an interesting survey. I would have liked to see a further breakdown of younger dentists versus older dentist to see if there was any difference. Personally after reviewing the recent literature I am in favor of IPT.

Treatment Options for Teeth with Open Apices and Apical Periodontitis

Kyung-Hong Cal Kim

Treatment Options for Teeth with Open Apices and Apical Periodontitis

Author: Raldi DP, Mello I, Habitante SM, Lage-Marques JL, Coil J.

JCDA October 2009

To compare 3 cases involving teeth with open apices and apical periodontitis

Background Information:
Challenges of treating teeth with open apices
-Time needed to form an apical barrier (with CaOH) is unpredictable and depends on the size of the apical foramen, the presence of infection, and the host.
-As instruments cannot  be used properly in teeth with open apices, cleaning and disinfection of the root canal system rely on the chemical action of NaOCl as an irrigant and CaOH as an intracanal dressing
-When rinsing immature teeth with open apices, there is an increased risk of pushing the irrigant beyond the apical foramen (use less concentrated NaOCl to irrigate)
Case 1
-16 y/o girl with subluxation trauma at 10 years of age
-Pain from tooth #11, sensitive to percussion and palpation, sinus tract b/w 11 and 12
-Open apices with apical periodontitis #11,12

-CaOH + saline placed in the canal, access sealed with Cavit
1 week later,
-CaOH was removed by rinsing with 1% NaOCl
-Paste of CaOH + 2ml of polyethylene glycol 400 was placed as an intracanal dressing
-Renewed dressing every 2 months for 1 year
1 year later,
-Canals were flushed with 5ml of 1% NaOCl followed by 5ml of 17% EDTA
-Obturation by lateral compaction, using gutta-percha

Case 2
-30 y/o woman with an endo-treated tooth #47 (treated at age 13)
-Gingival swelling
-Inadequate RCT, apical periodontitis radiographically

-CaOH + saline as an intracanal dressing
2 weeks later,
-Dressing was flushed out with 1% NaOCl
-MTA plug was adapted to the apical canal walls using a gutta percha point that was adjusted to 3mm short of WL
-Wet cotton pellet was placed on top of the plug, sealed access with Cavit
1 week later,
-Lateral compaction of gutta-percha + AH Plus sealer over the set apical MTA plug

Case 3
-28 y/o woman with subluxation trauma of tooth 11 at 7 years of age
-Uncomplicated crown fracture with normal mobility and darkening of the clinical crown
-Very immature tooth with a wide open apex and apical periodontitis

-CaOH + saline as an intracanal dressing
4 weeks later
-MTA mixture was condensed apically using large paper points
-Filled the remaining canal with MTA as the root canal was very wide
-Cotton pellet moistened in saline was placed over MTA in the pulp chamber and access was sealed with Cavit
-Later restored w/ composite


Tuesday, August 21, 2012

Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives-Permanent Teeth

Resident Name: Sadler
Article Info: Vital Pulp Therapy with New Materials: New Directions and Treatment Perspectives-Permanent Teeth
David E. Witherspoon BDS
Pediatric Dentistry V 30 No 3 May/Jun 08
Main Purpose: Discussion of present techniques and materials used in pulpal therapy of permanent teeth.
Key Points:
·         MTA is the optimum material for use in vital pulp therapy
·         MTA has some antibacterial properties but less than CaOH, however it seals much better
·         The dentin formed beneath MTA is thicker and stronger than that of CaOH and has more calming effect on vital pulp tissue
·         Controlling bleeding with vital pulp capping is essential and should be accomplished with NaOCl.  Once bleeding is controlled, MTA should be placed.  Success rates range from 93-98%
·         MTA is also very good for pulpotomy success  93-100%
·         In vital teeth with incomplete roots, MTA is the treatment of choice for pulp therapy.
Assessment of Article: Very nice read about MTA and how great it is.  It seems to combine a lot of what other studies have said already and MTA seems to be the best.  Update: MTA is currently only available from two suppliers (Proroot MTA-Dentsply) and a Brazilian company Angelus (Fillapex).  I’m not sure if the Angelus is FDA approved for use in the US but it is used elsewhere in the world. 

Importance of the Diagnosis in the Pulpotomy of Immature Permanent Teeth

Resident: Jeff Higbee

Journal: Braz Dent J (2007) 18(3): 244-247

Title: Importance of the Diagnosis in the Pulpotomy of Immature Permanent Teeth

Author: Ronaldo Ara├║jo SOUZA, et al

Main Purpose: Is periapical bone rarefaction actually a contraindication for pulpotomy therapy?

Main Points:

-        2 cases presented in which a pulpotomy was performed on 2 separate immature permanent molars

-        7 yr old female pt and a 6 yr old male pt

-        Each tooth had PA lesions

-        Each tooth was treated the same way using same materials (pulpotomy, calcium hydroxide, ZOE)

-        Non healthy pulp was removed

-        In immature teeth before necrosis occurs, chemical mediators of bone resorption, enzymes and products from protein decomposition may cross the remaining healthy pulp tissue and cause periradicular alterations (Langeland K. Management of the inflamed pulp associated with deep carious lesion. J Endodon 1981;7:169-181.). In spite of their pulp condition these teeth may develop PA lesions

-        These teeth need to be pulp tested prior to any tx decisions

-        Dx should not be solely based on radiographic data

-        Tests should include, percussion, palpation, pulp vitality accompanied by evaluation of pulp firmness, color and type of bleeding


-        Good article with good information

-        Very small sample size

-        Didn't talk about final restoration