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CHAPTER 2

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• Full complement of primary dentition

• Carious lesions on the maxillary right primary lateral incisor (FIL) and the maxillary left primary lateral incisor (F)

• Facial decalcification on the maxillary primary central incisors

• Occlusion: bilateral mesial step molar relationship, bilateral class I canine occlusion, midline aligned; 2 mm overjet, 90% overbite

I. Diagnostic Tools

• Maxillary anterior periapical radiograph (size 2 film) was obtained (see Figure2.4.3)

• Bitewing radiographs were not indicated due to open contacts and visual absence of caries per American Academy of Pediatric Dentistry (AAPD) guidelines (AAPD 2018–2019a)

Differential Diagnosis

• Not applicable

K. Diagnosis

• Early childhood caries

•

Manage facial decalcification on the maxillary primary

central incisors with a prescription remineralizing product such as those containing amorphous calcium phosphate

• Prevention plan: Three‐month periodic dental examination Oral hygiene instructions Dietary counseling Use of fluoridated toothpaste and consumption of fluoridated water

FUNDAMENTAL POINT 1

Anticipated Treatment Difculties

•

Patient cooperation due to age and parent’s

prediction of behavior

• Isolation of tooth as a result of proximity of caries to gingiva

L. Treatment Plan

• Maxillary right primary lateral incisor (FIL) resin restoration

• Maxillary left primary lateral incisor (F) resin‐modified glass ionomer (RMGI) cement (see Background Information 1)

Figure 2.4.3 Preoperative maxillary occlusal radiograph.

Restorative Treatment fortheMaxillary

M. Left Primary Lateral Incisor

• Restoration with RMGI cement (AAPD 2018–2019b) (see Fundamental Points 1 and 2)

N. Prognosis

• The prognosis for this site to remain caries free is good due to the fluoride‐releasing property of the restorative material, which reduces the chance of recurrent caries

• High success for retention is expected because the restoration is not subjected to high occlusal force and it chemically bonds to the tooth structure

O. Alternative Treatment

• Interim therapeutic restoration

• Less invasive restorative technique without local anesthetic (see Fundamental Point 3)

• Gross caries removal with hand instruments ( excavator and hatchet)

• Slow‐speed rotary instrument with light pressure may be used to improve cavity design

• Restorative material is usually glass ionomer cement or RMGI

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FUNDAMENTAL POINT 2

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RESTORATIVE DENTISTRY

Class V Preparation (Figure2.4.4)

• Nitrous oxide conscious sedation was used for behavior management

• Local anesthetic was not necessary for this patient

• Cotton roll isolation was adequate

• The cavity outline is kidney‐shaped and followsthe extent of the lesion to provide retention

• This may be done with a number 330 carbide or diamond bur

• Removal of caries was done using a slowspeed round bur

• The cavosurface margins of the cavity preparation must be 90° (butt joint)

Figure 2.4.4 Class V cavity preparation.

Placement ofResin‐Modied Glass Ionomer

• Place a retraction cord, if necessary

• Mix powder and liquid components of the RMGI thoroughly, following manufacturer’s directions, and load into an appropriate syringe tip

• The dentin is conditioned/primed (depending on brand used) according to the manufacturer’s recommendation

• Inject the mixed RMGI into the cavity preparation and condense with a hand instrument to eliminate any voids

• The instrument may be dabbed in a bonding agent to prevent the RMGI from sticking to it andpulling the restoration out of the cavity preparation. It also reduces the surface restoration

• Contour and remove excess material

• Light cure for approximately 40 seconds, placing the light as close to the restoration as possible without touching it

Finishing ofResin‐Modied Glass Ionomer

• Finishing with a rotary instrument may not be necessary if the above steps were done properly

• Use of a nishing bur at very low speed to reduce roughness is appropriate

• The RMGI should have an unlled resin adhesive placed over the nal restoration surface

roughness of the

BACKGROUND INFORMATION 1

Properties ofResin‐Modied Glass Ionomer

• Chemically bonds to enamel and dentin

• Releases fluoride

• Provides acceptable esthetics

• Less moisture sensitivity than resin‐based composite

Indications forClass V Glass Ionomer Cement Restoration

• Difficulty isolating the tooth (less moisture sensitive than resin‐based composite)

• Poor patient behavior (easy and fast)

• Moderate caries risk (fluoride release

(Croll and Nicholson 2002; Berg 2002; Berg and Croll 2015; Waggoner 2015)

FUNDAMENTAL POINT 3

Indications forInterim Therapeutic Restoration

• Uncooperative patients that will be managed nonpharmacologically

• Patients with special needs

• Interim restoration for caries control

• Instances in which other restorative materials cannot be used (AAPD 2018–2019c)

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Self‐Study Questions

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RESTORATIVE DENTISTRY

1. What are the properties of RMGI?

2. What are the indications for class V GIC restoration?

3. What are the indications for interim therapeutic restoration?

4. How should an RMGI restoration be nished?

Answers are located at the end of the case

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CHAPTER 2

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Self‐Study Answers

1. Chemical bonding to enamel and dentin, release of fluoride, acceptable esthetics, less moisture sensitivity than resin‐based composite

2. Difficult tooth isolation, poor patient behavior, patients with moderate caries risk

3. Uncooperative patients who will be managed nonpharmacologically, patients with special needs,

Bibliography

American Academy of Pediatric Dentistry. 2018–2019a.

Prescribing dental radiographs for infants, children, adolescents, and individuals with special health care needs. In:

Clinical Practice Guidelines and Best Practices (Reference Manual). Pediatr Dent 40:213–15. https://www.aapd.org/

research/oral‐health‐policies‐‐recommendations/prescribing‐ dental‐radiographs‐for‐infants‐children‐adolescents‐and‐ individuals‐with‐special‐health‐care‐needs

American Academy of Pediatric Dentistry. 2018–2019b.

Pediatric restorative dentistry. In: Clinical Practice Guidelines and Best Practices (Reference Manual). Pediatr Dent 40:330–42. https://www.aapd.org/research/oral‐health‐policies‐‐ recommendations/pediatric‐restorative‐dentistry

interim restoration for caries control, when other restorative materials cannot be used

4. Finishing with a rotary instrument may not be necessary if steps in placing restoration are done properly, a finishing bur at very low speed reduces roughness, place an unfilled resin adhesive over the final restoration

American Academy of Pediatric Dentistry. 2018–2019c. Policy

on interim therapeutic restorations (ITR). In: Clinical Practice

Guidelines and Best Practices (Reference Manual). Pediatr Dent 40:58–9. https://www.aapd.org/research/oral‐health‐

policies‐‐recommendations/interim‐therapeutic‐restorations

Berg JH. 2002. Glass ionomer cements. Pediatr Dent

24(5):430–8.

Berg JH, Croll TP. 2015. Glass ionomer restorative cement

systems: an update. Pediatr Dent 37(2):116–24.

Croll TP, Nicholson JW. 2002. Glass ionomer cements in

pediatric dentistry: review of the literature. Pediatr Dent 24(5):423–9.

Waggoner WF. 2015. Restoring primary anterior teeth: update

for 2014. Pediatr Dent 37(2):163–70.

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Case 5

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Class V Resin Restoration

Figure 2.5.1 (A, B) Facial photographs.

A. Presenting Patient

• Four‐year‐, ten‐month‐old Asian female (Figure2.5.1)

• New patient visit

B. Chief Complaint

• Mother states, “My daughter needs a check‐up and is very nervous”

C. Social History

• Patient is in preschool

• Lives with mother

• Patient has a sister (six years old)

• Mother is the primary caregiver and works full time

• Socioeconomic status is lower‐level

D. Medical History

• Patient was hypoglycemic at birth and was kept in the hospital for observation (see Fundamental Point 1).

• No medications

• No known disease and no history of allergies

E. Medical Consult

• Not necessary at this time

F. Dental History

• Prior to this visit the patient has not been to dentist in more than two years

• Patient was fearful and anxious about the dental examination

• Optimal water fluoridation levels

RESTORATIVE DENTISTRY

•

Moderately cariogenic diet, including one and a half

cups of juice daily

• Toothbrushing without supervision twice daily

FUNDAMENTAL POINT 1

Hypoglycemia

• Obtain a complete understanding of hypoglycemia:

When was the most recent hypoglycemic episode and has the patient experienced any complications from being hypoglycemic? Has the patient been placed on a special or restricted diet?

• Be prepared to manage a patient that becomes hypoglycemic while in your care:

A patient who is conscious can receive oral carbohydrates in the form of cake frosting. Iforal carbohydrates are ineffective, medical assistance should be called to the scene. Fifty percent dextrose can be administered by an intravenous catheter if the patient becomes unconscious. However, if intravenous access is unavailable, glucagon can be administered intramuscularly (Malamed 2000)

Extraoral Exam (Figure2.5.1)

• No significant findings

H. Intraoral Exam (Figure2.5.2)

• Primary dentition

• Exfoliating lower central incisors

• Occlusion: 1 mm overjet, 10% overbite; generalized spacing in anterior, closed contacts in posterior; 2 mm diastema; mesial step primary molars, class I canines (see Fundamental Point 2)

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CHAPTER 2

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Figure 2.5.2 (A–E) Preoperative photographs.

• Soft tissues: within normal limits

• Moderate plaque accumulation

• Oral hygiene is poor

• Multiple carious lesions

I. Diagnostic Tools

• See American Academy of Pediatric Dentistry (AAPD) radiographic guidelines (AAPD 2018–2019a)

• Two bitewing radiographs (Figure2.5.3)

• Anterior maxillary and mandibular periapical radiographs (Figure2.5.4)

• Radiographs show multiple carious lesions

K. Diagnosis andProblem List

Diagnosis

• Multiple carious lesions

• Poor oral hygiene

Problem List

• High caries risk due to cariogenic diet, poor oral hygiene, and history of decay

• Generalized plaque accumulation

• No dental home

J. Differential Diagnosis

• Not applicable

A B

Figure 2.5.3 (A, B) Bitewing radiographs.

Figure 2.5.4 (A) Anterior maxillary; (B) Anterior mandibular radiographs.

FUNDAMENTAL POINT 2

Orthodontic Evaluation

• Malocclusion: orthodontic evaluation in primary dentition:

Identify all anomalies of tooth number and size Identify any anterior or posterior crossbites if present Address the presence of habits along with their skeletal or dental sequelae

(AAPD 2018–2019b)

L. Comprehensive Treatment Plan

• Establish a dental home and reduce apprehension for dental care

• Prevention plan:

Dental prophylaxis Fluoride treatment (5% fluoride varnish placed) (seeFundamental Point 3) Review oral hygiene with parent and child Recommend use of floss

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• Three‐month recall:

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Re‐evaluate oral hygiene status and caries risk

• Restore decayed teeth (see Fundamental Point 4): Maxillary left primary canine‐facial decay: resin restoration Maxillary right primary first molar‐distal decay: stainless steel crown Address apprehensive behavior: recommend use of nitrous oxide/oxygen

• Attempt to remineralize the incipient lesions with a

remineralizing product such as those containing amorphous calcium phosphate:

Maxillary right primary second molar‐mesial incipient lesion Mandibular left primary second molar‐mesial incipient lesion Mandibular left primary first molar‐distal incipient lesion Mandibular right primary second molar‐mesial incipient lesion

RESTORATIVE DENTISTRY

Figure 2.5.7 Placement of resin.

M. Treatment

• Treatment (see Background Information 1): Local anesthesia: 36 mg of lidocaine with 1:100 000 epinephrine was administered Rubber dam isolation: a clamp was placed on the maxillary left primary second molar to achieve isolation (Figures2.5.5–2.5.8)

• Behavior management was achieved with nitrous

oxide sedation and tell‐show‐do technique

Figure 2.5.5 Rubber dam isolation.

Figure 2.5.6 Placement of bonding agent.

Figure 2.5.8 Final restoration.

Prognosis andDiscussion

• The prognosis for future caries is poor due to the patient’s moderate cariogenic diet and poor oral hygiene. Prognosis could be improved with implementation of the proposed prevention plan. Efforts should be made to reduce the patient’s anxiety, to wean off the nitrous oxide, and establish a comfort level with dental care

FUNDAMENTAL POINT 3

Fluoride Varnish

• Due to the patient’s high caries risk and young age, uoride varnish was placed. Fluoride varnish may be substituted for the traditional topical uoride treatment for the caries‐active preschooler. Varnish may be applied after the prophylaxis and may be ossed through tight contacts (Soxman 2005). It is easily applied and enhances remineralization. Three‐yearly applications of uoride varnish have been used effectively for children under the age of ve (Featherstone 2006)

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O. Complications andAlternative TreatmentPlan

• Should the treatment plan be more aggressive to manage the patient’s decay?

• Would daily use of a fluoridated mouthrinse be effective in remineralizing the incipient lesions?

• If the patient lived in a nonfluoridated community would treatment differ?

FUNDAMENTAL POINT 4

Selection ofRestorative Material

• The class V lesion in this patient was restored with a resin composite. It was chosen due to esthetics and its resistance to wear. Resin‐ based composites are available in a variety of shades and opacities and their physical and mechanical properties are excellent (Waggoner and Nelson 2019)

• According to the Pediatric Restorative Dentistry Consensus Conference held in SanAntonio, Texas, in 2002, a class V lesion in primary teeth can be restored with a resin‐based composite. The tooth, however, must be adequately isolated to prevent salivacontamination (AAPD 2002). This was again recommended through the AAPD in 2015 (Donly and Garcia‐Godoy 2015; Waggoner 2015)

BACKGROUND INFORMATION 1

Class V Resin‐Based Composite Restoration

• Class V restorations are often needed on the facial of cuspids. The caries should be removed with a 330 bur until dentin is reached. The bur is then moved laterally into sound dentin and enamel to create the walls of the cavity. The pulpal wall should be convex, following the shape of the outer enamel surface. The lateral walls should be slightly ared near the proximal surfaces to prevent undermining of the enamel. A short bevel is then placed around the entire cavosurface margin (Waggoner and Nelson 2019, Waggoner 2015). It is important to place a beveled enamel margin and a butt cementum/ dentin margin to enhance retention of the resin

In addition, several clinical steps must be taken

• to allow the resin to adhere to the tooth structure. Mechanical retention is achieved by flowing the water‐tolerant primer into the surface of the dentin where it permeates into the spaces of the collagen that were created by the acid etch. The primer will then allow the hydrophobic bonding agent to bond to the wet surface of the dentin. The bonding agent then bonds to the primer and the composite resin (Berg 1998). The resin can then be finished and polished

• If silver diamine fluoride had previously been applied to arrest caries, there will not be an adverse effect on the bond to dentin (Quock etal. 2012)

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