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.





Saturday, August 29, 2015

Teething in Infants


Teething is the phenomena accompanying growth of teeth through the gums. The effect of teething on infant health has been debated for at least 5000 years, and traditional beliefs on the issue have still not been entirely superseded by scientific findings. Sumerians believed teething and worm infestation were associated. Hindu writings, as well as work by Aristotle, Homer, Celsus, and others, describe associations between teething and illness. Many of these authors implicated tooth emergence in childhood mortality. The belief that teething led to childhood mortality, seizures, diarrhea, fever, or other serious conditions was criticized as early as the 17th century by Francois Ranchin. Yet in 1839, 5016 deaths in England and Wales were attributed to teething. Illingworth wrote in 1975 that “teething produces nothing but teeth.” However, as recently as 1979, parents and physicians were identifying teething as a cause of presenting symptoms in children admitted to the hospital. A medical evaluation of 50 of these children showed that in 48 cases the symptoms, ranging from upper respiratory infection to bacterial meningitis. Most medical professionals now agree that teething does not cause life-threatening illness, but they disagree about which symptoms may be associated with tooth eruption.

Teething in Infants

However several studies with different study designs has revealed symptoms believed to be associated with teething such as loss of appetite for solids and liquids, drooling, biting or chewing various objects, congestion or runny nose, cough, sleep disturbances, restlessness and irritability, rash, spitting up or vomiting, and diarrhea and fever or mild temperature elevation. Anyhow It is important to inform parents that none of these symptoms consistently and accurately predict when teething is about to occur and any of other organic disorders should be ruled out in infants with these symptoms.
The recommended intervention for teething is the use of cold items because the cold acts as an anesthetic for the gums. Refrigerated pacifiers, Spoons, Clean wet washcloths, Frozen bagels or bananas, refrigerated teething rings can be offered to the infants at this stage.Topical teething gels sold over-the-counter (OTC) are often used for teething but may carry serious risks, including local reactions, seizures with overdose, and methemoglobinemia. Benzocaine containing teething gels should not be used in infants or children under 2 years of age. If necessary, parents should be instructed on proper dosing of analgesic medications, such as acetaminophen or ibuprofen.


Saturday, October 19, 2013

Pulp therapy for primary teeth



Primary objective of pulp therapy is to maintain the integrity and health of the teeth and their supporting tissues by maintaining the vitality of the pulp of a tooth affected by caries, traumatic injury or any other cause damaging the liveliness of the pulp.
Indication and the type of the pulp therapy depends on the status of the pulp, whether it’s nonvital or vital and the type of the tooth whether its primary, young permanent or permanent. Status of the pulp would be determined by clinically with a proper history and a thorough clinical examination and by accurate special investigations such as vitality testing and radiographs. In this article I would mainly consider on the treatments to the pulp in primary teeth.


Vital pulp therapy for primary teeth diagnosed with a normal pulp or reversible pulpitis

Indirect pulp treatment
A procedure performed in a tooth with a deep carious lesion approximating the pulp but without signs and symptoms of pulp degeneration. The caries surrounding the pulp is left in place to avoid pulp exposure and is covered with a biocompatible material. A radiopaque liner such as a dentin bonding agent, resin modified glass ionomer, calcium hydroxide, zinc oxide-eugenol or glass ionomer cement is placed over the remaining carious dentin to stimulate healing and repair. Then the tooth is restored with a material that seals the tooth from micro leakage.



Direct pulp treatment
When a pinpoint mechanical exposure of the pulp is encountered during cavity preparation or following a traumatic injury a biocompatible radiopaque base such as mineral trioxide aggregate (MTA) or calcium hydroxide may be placed in contact with the exposed pulp tissue. Finally the tooth should always be restored with a material that seals the tooth from micro leakage.


Pulpotomy
A pulpotomy is performed in a primary tooth with extensive caries but without evidence of radicular pathology when caries removal results in a carious or mechanical pulp exposure. The coronal pulpotomy is amputated and the remaining vital radicular pulp tissue surface is treated with a medicament such as Buckley’s solution of formocresol. Gluteraldehyde and calcium hydroxide have been used but with less long term success. MTA is a more recent material with a high rate of success in pulpotomies. The coronal pulp chamber can be filled with zinc-oxide eugenol or other suitable base followed by acoronal restoration to avoid micro leakage and failure of the treatment. The most effective long term restoration has been shown to be a stainless steel crown although other alternatives such as composite resin and amalgam play a role when an adequate amount of enamel is intact.


Nonvital pulp therapy for primary teeth diagnosed with irreversible pulpitis or necrotic pulp

Pulpectomy
This involves the complete amputation of the pulpal tissue in a tooth that is reversibly infected or necrotic due to caries or trauma. The root canals are debrided mechanically with hand or rotary files and chemically with disinfectants such as sodium hypochlorite or chlorhexidine to ensure optimal bacterial decontamination of the canals. After proper drying of the canals a resorbable material such as non-reinforcedzinc oxide-eugenol, iodoform based paste or a combination paste of iodoform and calcium hydroxide is used to seal the canals.Then the tooth is restored with a material that seals the tooth from micro leakage.


Thursday, October 17, 2013

The history of dentistry


A profession that is ignorant of its past experiences has lost a valuable asset because “it has missed its best guide to the future.” 
B.W. Weinberger Dentistry: An Illustrated History 
(Mosby, 1995)

Ancient  Dentistry
The Indus Valley Civilization has yielded evidence of dentistry being practised as far back as 7000 BC.
Earliest form of dentistry involved curing tooth related disorders with bow drills operated, perhaps, by skilled bead craftsmen.In what could be one of the earliest examples of dentistry.Scientists at the University of Missouri-Columbia in the United States have found tiny, perfectly rounded holes in teeth found in Mehrgarh in pre-historic Pakistan, which they suspect were drilled to repair tooth decay.Researcher Andrea Cucina, who first discovered the tiny holes, reveals that they didn't appear to be a funeral rite and the teeth were still in the jaw so they had not been drilled to make a necklace. He and his colleagues suspect the holes were a treatment for tooth decay and that plants or another substance had been inserted into the holes to prevent bacterial growth.

The earliest dental filling, made of beeswax, was discovered in Slovenia and dates from 6500 years ago.
The first and most enduring explanation for what causes tooth decay was the tooth worm, first noted by the Sumerians around 5000 BC. The hypothesis was that tooth decay was the result of a tooth worm boring into and decimating the teeth.The idea of the tooth worm has been found in the writings of the ancient Greek philosophers and poets, as well as those of the ancient Indian, Japanese, Egyptian, and Chinese cultures. It endured as late as the 1300s, when French surgeon Guy de Chauliac promoted it as the cause of tooth decay.
Examination of the remains of some ancient Egyptians and Greco-Romans reveals early attempts at dental prosthetics and surgery.Ancient Greek scholars Hippocrates and Aristotle wrote about dentistry, including the eruption pattern of teeth, treating decayed teeth and gum disease, extracting teeth with forceps, and using wires to stabilize loose teeth and fractured jaws. Some say the first use of dental appliances or bridges comes from the Etruscans from as early as 700 BC.


The ancient dentist
 The Egyptian,Hesi-Re was the earliest dentist whose name is known. He practiced in 3000 BC and was called “Chief of the Toothers.” Egyptian pharaohs were known to have suffered from periodontal disease. Radiographs of mummies confirm this fact.

Dental extractions
Historically, dental extractions have been used to treat a variety of illnesses. During the Middle Ages and throughout the 19th century, dentistry was not a profession in itself, and often dental procedures were performed by barbers or general physicians. Barbers usually limited their practice to extracting teeth which alleviated pain and associated chronic tooth infection.Before the 18th century, this often involved tying a string around the tooth; a drum might be played in the background to distract the patient, getting louder as the moment of extraction grew nearer. To advertise their services as ‘tooth-pullers’, many barber-surgeons hung rows of rotten teeth outside their shops.


The Armentariam
Dental Pelican

Dental Key


Instruments used for dental extractions date back several centuries. In the 14th century, Guy de Chauliac invented the dental pelican (resembling a pelican's beak) which was used to perform dental extractions up until the late 18th century. The pelican later gave way to the Dental Key which, in turn, was replaced by modern forceps in the 20th century.


The equipments
The first dental foot engine was built by John Greenwood in 1790 . It was made from an adapted foot-powered spinning wheel.
John Greenwood

1790 was a big year for dentistry, as this was also the year the first specialized dental chairwas invented. It was made from a wooden Windsor chair with a headrest attached.In 1871, George F. Green invented the first electrical dental engine and in 1957, John Borden invented the first high speed electric hand drill.





The father of modern dentistry
By 17th-century French physician Pierre Fauchard (1678 – 1761) started dentistry as it is known today, and he has been named "the father of modern dentistry".He is tremendously recognized for his book, Le chirurgiendentiste, "The Surgeon Dentist" 1728, where he described the basic oral anatomy and function, signs and symptoms of oral pathology, operative methods for removing decay and restoring teeth, periodontal disease, orthodontics, replacement of missing teeth, and tooth transplantation. His book is said to be the first complete scientific description of dentistry. Among many of his developments were the extensive use of dental prosthesis, the introduction of dental fillings as a treatment for dental caries and the statement that sugar derivative acids such as tartaric acid are responsible for dental decay.


Women in dentistry
Women in pre-20th century seems to play an unknown role in dentistry. In an early copper engraving by Lucas Van Leyden, a traveling dentist can be seen along with a woman acting as his assistant.  In 1852, AmaliaAssur became the first female dentist in Sweden. She was given special permission from the Royal Board of Health to practice independently as a dentist, despite the fact that the profession was not legally opened to women in Sweden until 1861. 

Emeline Roberts Jones became the first woman to practice dentistry in the United States in 1855.  She married the dentist Daniel Jones when she was a teenager, and became his assistant in 1855 and later on put up her own practice. Rosalie Fougelberg in 1866 became the first woman in Sweden to officially practice dentistry when profession was legally opened to females in 1861.
Dental schools throughout the world did not accept female students. Women such as Lucy B. Hobbs-Taylor and Nellie E. Pooler broke those barriers. In 1866 Lucy Hobbs Taylor became the first woman to graduate from a dental college which was the Ohio Dental College.

Dental education
Dr. John M. Harris started the world's first dental school in Bainbridge, Ohio, and influenced establishing dentistry as a health profession. It opened on 21 stFebruary 1828, and today is a dental museum. The first dental college, Baltimore College of Dental Surgery, opened in Baltimore, Maryland, USA in 1840.Chapin Harris and Horace Hayden founded the Baltimore College of Dental Surgery, the first school dedicated solely to dentistry. The college merged with the University of Maryland School of Dentistry in 1923, which still exists today.


History of the tooth brush
A recent researches reveals that the earliest use of toothbrushes may have occurred in India and Africa. It was discovered that a bristle toothbrush had been used there as early as 1600 BC. The first bristle toothbrush found was in China during the Tang Dynasty (619–907) and used hog bristle. In 1223, Japanese Zen master DōgenKigen recorded on Shōbōgenzō that he saw monks in China clean their teeth with brushes made of horse-tail hairs attached to an ox-bone handle. The bristle toothbrush spread to Europe, brought back from China to Europe by travellers. It was adopted in Europe during the 17th century. Many mass-produced toothbrushes, made with horse or boar bristle, were imported to England from China until the mid-20th century.The first patent for a toothbrush was by H. N. Wadsworth in 1857 in the United States, but mass production in the United States only started in 1885. During the 1900s, celluloid handles gradually replaced bone handles in toothbrushes. Natural animal bristles were also replaced by synthetic fibers, usually nylon, by DuPont in 1938. The first nylon bristle toothbrush, made with nylon yarn, went on sale on February 24, 1938. The first electric toothbrush, the Broxodent, was invented in Switzerland in 1954.

The first publication on dentistry

The first book focused solely on dentistry was the "ArtzneyBuchlein" in 1530 and the first dental textbook written in English was called "Operator for the Teeth" by Charles Allen in 1685.
 

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