Restorative Dentistry for the Primary Dentition










CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281
3. World Health Organization. International Statistical Classication of
Diseases and Related Health Problems. ICD-10: 10th Revision, 2016.
4. American Academy of Pediatric Dentistry. Policy on child identication
programs. Academy of Pediatric Dentistry Council on Clinical Aairs.
Pediatr Dent. 2016;38(6):32–33.
5. Armitage GC. Periodontal diagnoses and classication of periodontal
diseases. Periodontol 2000. 2004;34(1):9–21.
6. American Academy of Pediatric Dentistry. Pediatric medical history.
Pediatr Dent. 2016;38(6):428–430.
7. Boyle EM, Poulsen G, Field DJ, et al. Eects of gestational age at
birth on health outcomes at 3 and 5 years of age: population based
cohort study. BMJ. 2012;344:e896.
8. Szczepaniak D, McHenry MS, Nutakki K, et al. e prevalence of
at-risk development in children 30 to 60 months old presenting with
disruptive behaviors. Clin Pediatr (Phila). 2013;52(10):942–949.
9. Barton M. Screening for obesity in children and adolescents: US
Preventive Services Task Force recommendation statement. Pediatrics.
2010;125:361–367.
10. Centers for Disease Control and Prevention. About child and teen
BMI. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/
about_childrens_bmi.html. Accessed August 31, 2017.
11. Marcum B, Turner C, Courts F. Pediatric dentists’ attitudes regarding
parental presence during dental procedures. Pediatr Dent.
1995;17(7):432–436.
12. Cox CJ, Krikken JB, Veerkamp JS. Inuence of parental presence
on the child’s perception of, and behaviour, during dental treatment.
Eur Arch Paediatr Dent. 2011;12(4):200–204.
13. Fields HW, Vann WF. Prediction of dental and skeletal relationships
from facial proles in preschool children. Pediatr Dent. 1979;1:
7–15.
14. Fields HW, Vann WF. Prediction of dental and skeletal relationships
from facial proles in preschool children. Pediatr Dent. 1979;1:7–15.
15. Valachovic RW, Lurie AG. Risk-benet considerations in pedodontic
radiology. Pediatr Dent. 1980;2:128–146.
16. Brearly IL, McKibben DH. Ankylosis of primary molar teeth: parts
I and II. J Dent Child. 1973;40:54–63.
17. Kurol J, Koch G. e eect of extraction on infraoccluded deciduous
molars: a longitudinal study. Am J Orthod. 1985;87:46–55.
18. Messer LB, Cline JT. Ankylosed primary molars: results and treatment
recommendations from an eight-year longitudinal study. Pediatr
Dent. 1980;2:37–47.
19. Tieu LD, Walker SL, Major MP, et al. Management of ankylosed
primary molars with premolar successors: a systematic review. J Am
Dent Assoc. 2013;144:602–611.
20. White SC, Pharoah MJ. Oral Radiology: Principles and Interpretation.
7th ed. St Louis: Mosby; 2014.
21. Oral Health During Pregnancy Expert Workgroup. Oral Health Care
During Pregnancy. A National Consensus Statement. Washington, DC:
National Maternal and Child Oral Health Resource Center; 2012.
22. American Academy of Pediatric Dentistry. Guideline on prescribing
dental radiographs for infants, children, adolescents, and persons
with special health care needs. Pediatr Dent. 2016;38(6):355–357.
23. Innes NPT, Ricketts D, Chong LY, et al. Preformed crowns for
decayed primary molar teeth. Cochrane Database Syst Rev.
2015;(12):CD005512.
24. Mata AF, Bebermeyer RD. Stainless steel crowns versus amalgams
in the primary dentition and decision-making in clinical practice.
Gen Dent. 2006;54(5):347–350.
25. American Academy of Pediatric Dentistry. Behavior guidance for the
pediatric dental patient. Pediatr Dent. 2017;39(6):246–259.
26. Gao SS, Zhang S, Mei ML, et al. Caries remineralisation and arresting
eect in children by professionally applied uoride treatment—a
systematic review. BMC Oral Health. 2016;16:12.
preferred to restoration if pulpal therapy is likely to be unsuccessful.
Another example is the choice of a stainless steel crown rather
than a three-surface amalgam restoration in a caries-prone child
because fewer surfaces will be left exposed to recurrent caries, and
evidence supports recurrence of caries.
23,24
A frank assessment of the cooperation and involvement in
the child’s treatment by the family must be considered. Dental
treatment is necessarily a cooperative eort, with success resting
on both personal and professional maintenance. e behavioral
plan is critical to the success of the treatment plan in general. For
the 3- to 6-year-old child, the methods of behavior guidance to
be used must be included in the treatment plan for purposes of
consent and often third-party payment.
25
e sequence of managing
behavior, obtaining consent for medications, and providing reason-
able alternatives to recommended procedures should be covered in
discussion of the behavioral plan with the parents. Some dentists
prefer to explain and obtain consent for all behavior procedures
they might use at the initial case presentation to permit transition
from one to the next during a treatment encounter.
Generally, acute infection and pain are managed rst. Hopelessly
involved teeth should be extracted, although this can be a challenging
introduction to dental care for the young child. If numerous large
lesions are present, they may be excavated and interim restorations
placed. Use of glass ionomer cement, with its uoride release,
oers some additional preventive benet. is “rst aid” approach
reduces the chance of caries progression, with its resultant pain;
reduces diculty in cleaning; and reduces deleterious oral ora.
e introduction of silver diamine uoride can also be considered
part of the dental armamentarium when addressing dentinal caries
(see Chapter 12).
26
For more denitive care, if teeth with deep
lesions and chronic pulpal involvement are not painful, they can
be incorporated in a treatment plan that proceeds by quadrant or
sextant rather than being managed immediately.
All factors being equal, restorative care often is easiest in the
maxillary posterior areas. e inltration injections are easiest for
patients to tolerate. e dentist can then move to the mandibular
posterior sextants. Seldom are the mandibular anterior teeth involved
unless rampant caries are present.
Finally, the maxillary anterior teeth can be approached. is is
a good nal selection because the injections are uncomfortable,
and some families will not pursue all necessary care if the maxillary
anterior teeth are restored rst with a good esthetic result.
When restorative care is complete and the patient and parent
demonstrate that they can maintain good oral health, orthodontic
care, whether active or for space maintenance, can be considered.
It is best if space maintenance can be implemented in the rst 6
months after necessary extractions because space loss is most
common during this period (see Chapter 26).
References
1. American Academy of Pediatric Dentistry. Guideline on perinatal
and infant oral health care. Academy of Pediatric Dentistry Council
on Clinical Aairs. Pediatr Dent. 2016;38(6):150–154.
2. American Academy of Pediatric Dentistry. Guidelines for record-
keeping. Academy of Pediatric Dentistry Council on Clinical Aairs.
Pediatr Dent. 2016;38(6):343–350.

CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281.e1
Case Study: Examination and Treatment
Planning in the 3- to 6-Year-Old Patient
Bhavna T. Pahel
A female, 5 years and 9 months old, named Genny comes to visit you for a
comprehensive new patient exam. She is accompanied to the appointment
by her mother. The family has recently moved to the area from out of state.
Genny’s mother chose your practice because she saw excellent reviews on
the internet and received high recommendations for your practice from her
neighbors. She states that she is interested in establishing a dental home for
Genny in your practice.
Provide an overview of information you would obtain
about Genny before you proceed with your dental clinical
examination.
A pictorial description of the recommended steps as part of a systematic
new patient examination is provided in Fig. E19.1. As part of the medical
history, Genny’s mother indicates she was born full term and there were no
complications at birth. Genny has been vaccinated on schedule and her most
recent tetanus toxoid was given last summer before she started
kindergarten. Over the past year, Genny has developed exercise-induced
asthma, triggered by running outside in cold weather. She uses an albuterol
inhaler to control the symptoms. It is important for the clinician to review
any positive responses on the medical history questionnaire with follow-up
questions. In this case, upon further questioning, Genny’s mother reports the
last time the inhaler was used was 4 months ago. She has not needed oral
steroids nor visited the emergency room for asthma-related problems. Genny
has no other medical problems or allergies. Regarding the social history, her
mother states Genny is an only child and lives at home with both parents.
Although Genny has never visited a dentist, her mother has used books and
videos to prepare her for the dental visit today. According to her mother,
Genny “bumped her two upper front teeth” approximately 1 month ago while
playing on the sidewalk. Her mother had noticed some bleeding from the
gums around the two upper front teeth which was self-limiting. Genny did
not require treatment for that injury and she has not complained of
discomfort in those teeth. Genny used to suck her left thumb at night, but
the habit has stopped since she started kindergarten last year. The family
eats a healthy diet with an abundance of fruits and vegetables, and Genny
mainly drinks uoridated city water. Genny does have a sweet tooth and is
allowed to eat gummy candies about once a week. According to her mother,
it has been challenging to restrict her candy intake since she started
kindergarten. Genny brushes her teeth twice a day using uoride toothpaste
with occasional supervision from her mother or father, and she likes to oss
her own teeth at night. There is no history of mouthwash use.
You proceed with your clinical examination. Review
Fig. E19.2 and describe what you see in a systematic
manner.
Extraoral ndings: Genny’s prole is convex with 33% lower face height. She
has competent lips with mild protrusion of the upper lip. In the frontal
view, Genny appears to be fairly symmetric with some straining of the
lower lip. She has positive buccal corridors and good gingival display on
smile.
Intraoral soft tissue ndings: Soft tissues including, gingiva, frenula, tongue,
and oral mucosa appear healthy, the oor of the mouth is well perfused,
and the airway is Mallampati class I (Box E19.1).
Intraoral hard tissue ndings: The patient is in the primary dentition. The
primary buccal segments are intact, and no restorations or sealants are
noted. Minimal plaque is noted on the lingual surfaces of the mandibular
incisors and facial surfaces of the maxillary molars. Occlusion: (1)
Anteroposterior—second primary molars are in mesial step occlusion
and primary canines are in class I relationship bilaterally. The overjet is
3 mm; (2) Vertical—overbite is 80%; (3) Transverse—The midlines are
coincident. Pathology: There is no clinical evidence of dental caries.
Genny’s posterior contacts are closed so you proceed to obtain two
bitewing radiographs (Fig. E19.3). Given a past history of trauma to the
maxillary incisors, you also obtain a maxillary anterior periapical radiograph.
Use a systematic approach to interpret the radiographs.
The bitewings are of diagnostic quality and clearly show intact primary
buccal segments on the right and left. The alveolar bone levels are within
the range of normal. All four rst permanent molars (teeth #3, 14, 19, and
30) are evident on the radiograph. Incipient (enamel) caries is noted on the
distal surface of tooth #S and the mesial surface of tooth #T. No other dental
or bony pathology is noted. The maxillary anterior periapical radiograph
Medical history
Social history
Dental history
Habits
Diet
Oral hygiene
Extraoral findings
Intraoral findings
- Soft tissues
- Hard tissues
- Posterior contacts open
- History of dental trauma
- Posterior contacts closed and/or
- History of trauma present
No radiographs
Two bitewings and/or
periapical radiographs
- Preventive/maintenance
- Growth and development
- Restorative
- Behavior
Assessment and plan
Figure E19.1 Overview of a systemic approach to a new patient
clinical examination.
Data from Samsoon GL, Young JR. Difcult tracheal intubation: a retrospective study. Anaesthesia.
1987;42(5):487–490.
Class I—uvula, faucial pillars, and soft palate are visible
Class II—faucial pillars and soft palate are visible
Class III—soft palate is visible
Class IV—hard palate only is visible.
Mallampati Classication BOX E19.1
Continued

281.e2 Part 3 The Primary Dentition Years: Three to Six Years
exhibits no dental or bony pathology, and all permanent incisors appear to
be developing normally.
Based on your parent interview and clinical examination,
what is your assessment and plan to maximize Genny’s oral
health?
As depicted in Fig. E19.1, the comprehensive assessment and plan to
maximize Genny’s oral health should include the four domains of: (1)
preventive and maintenance plan; (2) growth and development; (3)
restorative plan; and (4) behavior guidance plan. Given the presence of two
proximal incipient caries lesions on teeth #S and #T, our focus should be on
the rst domain of prevention and maintenance by improving oral hygiene
practices and uoride exposure. The goal is to remineralize the incipient
lesions. Genny’s parents should be encouraged to supervise brushing twice
a day, and if Genny can spit reliably, an over-the-counter uoride mouthrinse
can be added to the nightly oral hygiene regimen to increase topical uoride
exposure. Diet modication to reduce candy consumption should also be a
part of the preventive plan. The recall frequency can be more frequent at 3
rather than 6 months to allow for closer monitoring of oral hygiene and
increasing exposure to topical uoride application in the dental ofce. Lastly,
given the high caries risk, Genny may benet from sealants on the food
retentive grooves of her primary molars. Her growth and development should
be monitored at regular recall visits. Given her excellent behavior at the rst
dental visit, all the preventive objectives likely can be achieved with standard
behavior management techniques, including tell-show-do and positive
reinforcement. All this information should be communicated to Genny’s
mother in a compassionate manner to avoid parental feelings of guilt. It
should be emphasized to the family that the dentist is a partner with them in
achieving the best oral health for their child.
Questions
1. Why is it important to determine who the child lives with or who the child
spends the most time with in a review of the child’s medical and social
history?
Answer: The clinician can determine several important factors in
planning comprehensive care for this patient. The primary caregiver’s
attitude toward general and oral health, the family’s dietary preferences,
their access to uoridated water, as well as the level of oral hygiene
supervision are just some of the factors determined in a review.
2. In a comprehensive clinical exam, what are the three basic areas of
examination? Why are these areas important for a dentist to examine?
Answer: The three areas of a comprehensive clinical exam include an
examination of (1) extraoral tissues; (2) intraoral soft tissues; and (3)
intraoral hard tissues. Extraoral ndings such as facial asymmetry may
provide clues as to the presence of trauma or infection. With respect to
intraoral soft tissues, the presence of unexplained gingival bleeding may
indicate the presence of a serious underlying medical condition such as a
blood dyscrasia or leukemia. A thorough evaluation of intraoral hard tissues
can provide important information regarding the patient’s occlusion, as well
as any pathology, including developmental defects, trauma, and dental
caries.
Figure E19.2 Extraoral and intraoral clinical photographs.

CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281.e3
3. Discuss the spectrum of behavior guidance strategies available to a
dentist for a 3-year-old child in need of restorative treatment.
Answer: The spectrum for treating a 3-year-old child in a safe and
compassionate manner is immense. If the child exhibits cooperative
behavior, basic behavior guidance strategies such as tell-show-do, positive
reinforcement, and distraction, in combination with nitrous oxide/oxygen
inhalation (as needed), may be effective in guiding the child’s behavior
during the dental appointment. Conversely, if the child exhibits
noncooperative behavior, the clinician can choose from a range of advanced
behavior management strategies including protective stabilization, oral
conscious sedation, and general anesthesia. The decision to use one or more
of these behavior guidance strategies should be based, among other factors,
on the child’s willingness and ability to cooperate, his or her medical history,
and the amount of dental treatment required.
Figure E19.3 Maxillary anterior periapical and bitewing radiographs.

282
20
Prevention of Dental Disease
ARWA I. OWAIS AND ARTHUR J. NOWAK
CHAPTER OUTLINE
Fluoride Administration
Dietary Fluoride Supplementation
Topical Fluoride Therapy
Professional Applications of Fluoride
Indications for Professional Topical Fluoride Applications
Cost-Benet Considerations
Prophylaxis Before Topical Fluoride Treatment
Method of Application
Considerations for Special Patients
Dietary Management
Dietary Counseling
Home Care
W
ith the eruption of all primary teeth, the preschool child
enters a relatively short period of dental stability in
preparation for the loss of the rst primary tooth and
the lengthy process of eruption of the permanent teeth. Historically,
many preschoolers’ rst dental examination occurred during this
period; however, with the increased awareness that home care
should be established much earlier for all children, a child might
have already established a dental home by this age. During this
stage, instructions are reinforced for appropriate oral hygiene
techniques and topical uoride use. After taking into consideration
the child’s caries risk, adjustments in optimal systemic uoride
supplementation should be considered if the child is living in a
nonuoridated community.
Dietary management may now become a problem. is is the
period of development of strong preferences for and aversions
to specific foods. The effect of commercials from television,
the Internet, and the press begins to take its toll. Children are
frequently sent to a child care facility for a quasieducational
experience, a babysitting service, or a true preschool developmental
experience. Parental control of the quality and quantity of the
diet is sometimes greatly sacriced due to the fact that other care
providers are often involved in preparing meals and snacks for
the children.
When the end of the day is in sight and the children want to
watch “just one more TV program,” or play “just one more game,
the daily supervised oral hygiene routine may be sacriced for the
quick 30-second unsupervised brushing. It is amazing how quickly
parents assume that 4-year-old children can be responsible for
their own oral hygiene when they cannot even comb their hair or
print their name clearly.
Fluoride Administration
Dietary Fluoride Supplementation
Recommendations on the prescription of dietary uoride supple-
mentation for caries prevention were revised in 2013.
1,2
Dietary
uoride supplementation should be prescribed only for children
who are at high risk of developing caries and whose primary
source of drinking water is decient in uoride. erefore the
rst step for the clinician is to determine if the child is at high
caries risk as described in Chapters 14 and 15. If the child
is at high risk for caries and drinks water that is decient in
uoride, then uoride supplementation should be considered
(Table 20.1).
1,2
e US Public Health Service (USPHS) currently recommends
an optimal uoride concentration of 0.7 mg/L. is replaces the
earlier USPHS recommendation for uoride concentrations of 0.7
to 1.2 mg which was based on outdoor air temperature of geographic
areas.
3
e new recommendation, which was supported by the
American Dental Association (ADA), does not change the ADA
Council on Scientic Aairs’ systematic review and clinical recom-
mendation for the use of dietary uoride supplements that was
released in 2010 (see Table 20.1).
By 3 years of age, most children are able to chew and swallow
tablets; therefore prescriptions for supplemental uoride should
be changed from liquid drops to chewable tablets to reect this
change in developmental status. e recommended supplemental
uoride dosage schedule also requires an increase in the amount
of uoride prescribed after a child reaches 3 years of age. e
recommended daily dosage of supplemental uoride is 0.5 mg for
children aged 3 to 6 years who drink water containing less than
0.3 ppm of uoride. e dosage is 0.25 mg for those whose water
contains between 0.3 and 0.6 ppm uoride. Children whose drinking
water contains more than 0.6 ppm of uoride do not require any
supplementation. However, the potential for producing dental
uorosis on permanent anterior teeth will have diminished in this
age group owing to substantial crown formation (see Chapter 15
for details on uorosis). e practice of determining the uoride
levels of each child’s drinking water before prescribing supplemental
uoride should continue. In the United States, information on
the uoride status of community water supplies, listed by state,
county, and city, can be accessed on the Centers for Disease Control
and Prevention (CDC) My Water Fluoride website (www.cdc.gov/
oralhealth/).
4
If the uoride level is unknown, then an analysis

CHAPTER 20 Prevention of Dental Disease 283
applications are often applied during this interval, and their use
should be based on caries risk assessment. One mode of topical
application that is generally not recommended for the younger
members of this age group is the use of uoride mouth rinses,
because most preschoolers are unable to avoid swallowing some
of these solutions.
5
Professional Applications of Fluoride
Topical application of highly concentrated forms of uoride has
been provided in clinical settings for many years. ere is evidence
that the use of 1.23% acidulated phosphate uoride (APF) and
5% sodium uoride varnish is eective in preventing dental caries
in children 6 years and older. However, a recent report of the ADA
Council of Scientic Aairs recommends only 2.26% uoride
varnish (5% sodium uoride varnish) for children younger than
6 years because it does not have the risk of experiencing adverse
events (particularly nausea and vomiting) associated with swallowing
other forms of uoride.
5
Fluoride varnish (Fig. 20.1) has become
a popular topical agent for preschool children and individuals with
special health care needs. It has been recommended for conditions
can be requested from the local public health department, family
dentist, or commercial laboratories.
Because parental compliance continues to play a key role in
determining the eectiveness of these supplements, eorts to
reinforce parental motivation should be made. One method of
assessing parental compliance is to monitor the need to rewrite
supplemental uoride prescriptions at recall visits. e dosage
of uoride prescribed should be noted in each patients record
whenever a prescription is written. Parents who indicate no
need for an additional prescription when the patients record
suggests that the previously prescribed supplement should
have been consumed should be questioned about the number
of tablets remaining. A large remaining supply suggests poor
compliance.
Topical Fluoride Therapy
Topical uorides have an increasingly important role in the 3- to
6-year-old group. e child’s ability to appropriately use uoride
dentifrices increases throughout this period, although parental
involvement at each brushing should continue. Professional topical
The expert panel convened by the American Dental Association Council on Scientic Affairs developed the following recommendations. They are intended
as a resource for dentists and other health care providers. The recommendations must be balanced with the practitioner’s professional judgment and
the individual patient’s needs and preferences.
Children are exposed to multiple sources of uoride. The expert panel encourages health care providers to evaluate all potential uoride sources and to
conduct a caries risk assessment before prescribing uoride supplements.
Recommendation Strength of Recommendations
For children at low risk of developing caries, dietary uoride supplements are not
recommended, and other sources of uoride should be considered as a caries-
preventive intervention
D
For children at high risk of developing caries, dietary uoride supplements are
recommended according to the schedule presented in the next section of the table
D
When uoride supplements are prescribed, they should be taken daily to maximize
the caries-preventive benet
D
Recommended American Dental Association Dietary Fluoride Supplement Dosing Schedule for Children at High Risk of Developing Caries
Age
AMOUNT OF FLUORIDE SUPPLEMENTATION AND STRENGTH OF RECOMMENDATIONS, ACCORDING TO
FLUORIDE CONCENTRATION IN DRINKING WATER (PARTS PER MILLION
a
)
<0.3 0.3 TO 0.6 >0.6
Fluoride
Supplementation
Strength of
Recommendations
Fluoride
Supplementation
Strength of
Recommendations
Fluoride
Supplementation
Strength of
Recommendations
Birth to 6 months None D None D None D
6 months to 3 years
0.25 mg/d B None D None D
3–6 years
0.50 mg/d B 0.25 mg/d B None D
6–16 years
1.00 mg/d B 0.50 mg/d B None D
a
1.0 part per million = 1 milligram per liter.
Strength of Recommendations: A, Directly based on category I evidence; B, directly based on category II evidence or extrapolated recommendation from category I evidence; C, directly based on category
III evidence or extrapolated recommendation from category I or II evidence; D, directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence.
From Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary uoride supplements for caries prevention. A report of the American Dental Association
Council on Scientic Affairs. J Am Dent Assoc. 2010;141(12):1480–1489.
Clinical Recommendations for the Use of Dietary Fluoride Supplements
TABLE
20.1

284 Part 3 The Primary Dentition Years: Three to Six Years
Cost-Benet Considerations
In a private practice setting, the patients willingness or ability to
pay for dierent forms of treatment usually is an important factor
in determining what types of services are provided. In the case
of public programs or private third-party payers, the decision to
provide reimbursement for various services may be based on a more
formal analysis of the relationship between the costs and benets
associated with those services. e ratio of costs to benets has
historically been higher for topical uoride applications provided
in dental oces than for other types of preventive services or
for the same services provided in other settings. Consequently,
professional topical uoride treatments have not been recom-
mended as a public health measure because of their unfavorable
cost-benet ratio.
Documented changes in caries levels and patterns of decay in
children in the United States have pushed these ratios even higher.
Studies have reported that a substantial proportion of school-aged
children in the United States are caries free and that a relatively
small percentage of children account for a large percentage of all
tooth decay.
11
In addition to the overall decline in the level of
caries, there has been a decrease in the proportion of smooth-surface
caries and a corresponding increase in the proportion of pit and
ssure caries. e combination of these factors seems to be associated
with a reduction in the eectiveness of concentrated topical uoride
therapy in terms of the actual number of surfaces saved from
becoming carious during a given period.
12
Changes of this nature have led some interested parties to call
for a reexamination of the manner in which various preventive
measures are provided. In an era when increased attention is being
focused on measures for controlling all types of health care costs,
some have proposed that consideration be given to making preven-
tive dental services more cost-eective. One means of improving
the cost-benet ratio of topical uoride therapy would be to provide
this therapy in settings other than dental oces, such as school-based
programs and home use. In addition, cost-eectiveness may be
enhanced by targeting those children at high risk for developing
caries.
A factor that has been repeatedly demonstrated to be associated
with a reduction in both the risk of developing caries and the
relative eectiveness of topical uoride therapy is the availability
of drinking water containing uoride. Studies have shown that
topical uorides are considerably more eective in reducing the
incidence of decay in nonuoridated areas compared with uoridated
areas.
13
erefore the cost of preventing a carious lesion in a uo-
ridated area by means of professional topical uoride therapy is
signicantly greater than the cost of preventing a lesion in a
nonuoridated area. is suggests that, in uoridated areas, topical
uoride treatments should be reserved for patients who have a
history of moderate to high caries development or who are in
proven high-risk categories. ose who do not seem to be particu-
larly prone to developing caries, especially smooth-surface decay,
would probably benet more from other forms of prevention such
as pit and ssure sealants. (See Chapter 33 for more details on pit
and ssure sealants.)
e question of which preventive services should be provided
for a particular child in the dental oce remains an individual
issue for dentists and their patients (or parents in the case of
children). Accordingly, the nal decision about professional preven-
tive services must be based on the childs risk assessment and made
by the child’s parents once informed on the costs and expected
benets. However, the inuence of third-party coverage for dierent
in which decalcied enamel secondary to poor plaque removal or
poor feeding practices is present.
6–8
A recent Cochrane review
found that the application of uoride varnish two to four times
a year is associated with a substantial reduction in caries increment.
9
e American Academy of Pediatrics (AAP) has also endorsed the
application of uoride varnish in children up to 5 years of age.
In summary, the evidence-based approach to clinical recom-
mendations should be integrated with the practitioner’s professional
judgment and the patient’s needs and preferences.
Indications for Professional Topical
Fluoride Applications
When and for whom topical application of fluoride should
be provided in the dental office has been a source of some
controversy. One school of thought invokes the argument that
professional uoride application is a primary preventive measure
and should be provided to all children to minimize the potential
for development of new carious lesions. Part of the historical
basis for this approach relates to the lack of validated methods
to predict whether an individual patient is likely to develop
caries. Advocates of this philosophy tend to focus only on the
potential benets that might be achieved from topical uoride
application while ignoring the costs associated with providing
the service.
Others feel that the decision to provide topical uoride therapy
should be based on the factors that have been shown to be associated
with the risk of developing caries in groups or in individuals (e.g.,
access to uoridated drinking water, use of other forms of topical
uoride, degree of spacing between teeth). eir approach is to
consider the likelihood that each patient develops disease according
to these caries risk factors and then to recommend professional
topical uoride therapy for those considered to be at signicant
risk for developing caries. Proponents of this philosophy tend to
consider the costs associated with providing the service as well as
the potential benets. Caries risk assessment methods are available
to help clinicians predict with accuracy which individuals are more
likely to develop caries and therefore would benet more from
topical uoride therapy.
10
Figure 20.1 Example of a uoride varnish. (Pictured: Vanish 5% sodium
uoride varnish. Courtesy 3M Science Applied to Life Inc., USA.)

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CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281 3. World Health Organization. International Statistical Classication of Diseases and Related Health Problems. ICD-10: 10th Revision, 2016.4. American Academy of Pediatric Dentistry. Policy on child identication programs. Academy of Pediatric Dentistry Council on Clinical Aairs. Pediatr Dent. 2016;38(6):32–33.5. Armitage GC. Periodontal diagnoses and classication of periodontal diseases. Periodontol 2000. 2004;34(1):9–21.6. American Academy of Pediatric Dentistry. Pediatric medical history. Pediatr Dent. 2016;38(6):428–430.7. Boyle EM, Poulsen G, Field DJ, et al. Eects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study. BMJ. 2012;344:e896.8. Szczepaniak D, McHenry MS, Nutakki K, et al. e prevalence of at-risk development in children 30 to 60 months old presenting with disruptive behaviors. Clin Pediatr (Phila). 2013;52(10):942–949.9. Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2010;125:361–367.10. Centers for Disease Control and Prevention. About child and teen BMI. http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Accessed August 31, 2017.11. Marcum B, Turner C, Courts F. Pediatric dentists’ attitudes regarding parental presence during dental procedures. Pediatr Dent. 1995;17(7):432–436.12. Cox CJ, Krikken JB, Veerkamp JS. Inuence of parental presence on the child’s perception of, and behaviour, during dental treatment. Eur Arch Paediatr Dent. 2011;12(4):200–204.13. Fields HW, Vann WF. Prediction of dental and skeletal relationships from facial proles in preschool children. Pediatr Dent. 1979;1: 7–15.14. Fields HW, Vann WF. Prediction of dental and skeletal relationships from facial proles in preschool children. Pediatr Dent. 1979;1:7–15.15. Valachovic RW, Lurie AG. Risk-benet considerations in pedodontic radiology. Pediatr Dent. 1980;2:128–146.16. Brearly IL, McKibben DH. Ankylosis of primary molar teeth: parts I and II. J Dent Child. 1973;40:54–63.17. Kurol J, Koch G. e eect of extraction on infraoccluded deciduous molars: a longitudinal study. Am J Orthod. 1985;87:46–55.18. Messer LB, Cline JT. Ankylosed primary molars: results and treatment recommendations from an eight-year longitudinal study. Pediatr Dent. 1980;2:37–47.19. Tieu LD, Walker SL, Major MP, et al. Management of ankylosed primary molars with premolar successors: a systematic review. J Am Dent Assoc. 2013;144:602–611.20. White SC, Pharoah MJ. Oral Radiology: Principles and Interpretation. 7th ed. St Louis: Mosby; 2014.21. Oral Health During Pregnancy Expert Workgroup. Oral Health Care During Pregnancy. A National Consensus Statement. Washington, DC: National Maternal and Child Oral Health Resource Center; 2012.22. American Academy of Pediatric Dentistry. Guideline on prescribing dental radiographs for infants, children, adolescents, and persons with special health care needs. Pediatr Dent. 2016;38(6):355–357.23. Innes NPT, Ricketts D, Chong LY, et al. Preformed crowns for decayed primary molar teeth. Cochrane Database Syst Rev. 2015;(12):CD005512.24. Mata AF, Bebermeyer RD. Stainless steel crowns versus amalgams in the primary dentition and decision-making in clinical practice. Gen Dent. 2006;54(5):347–350.25. American Academy of Pediatric Dentistry. Behavior guidance for the pediatric dental patient. Pediatr Dent. 2017;39(6):246–259.26. Gao SS, Zhang S, Mei ML, et al. Caries remineralisation and arresting eect in children by professionally applied uoride treatment—a systematic review. BMC Oral Health. 2016;16:12.preferred to restoration if pulpal therapy is likely to be unsuccessful. Another example is the choice of a stainless steel crown rather than a three-surface amalgam restoration in a caries-prone child because fewer surfaces will be left exposed to recurrent caries, and evidence supports recurrence of caries.23,24A frank assessment of the cooperation and involvement in the child’s treatment by the family must be considered. Dental treatment is necessarily a cooperative eort, with success resting on both personal and professional maintenance. e behavioral plan is critical to the success of the treatment plan in general. For the 3- to 6-year-old child, the methods of behavior guidance to be used must be included in the treatment plan for purposes of consent and often third-party payment.25 e sequence of managing behavior, obtaining consent for medications, and providing reason-able alternatives to recommended procedures should be covered in discussion of the behavioral plan with the parents. Some dentists prefer to explain and obtain consent for all behavior procedures they might use at the initial case presentation to permit transition from one to the next during a treatment encounter.Generally, acute infection and pain are managed rst. Hopelessly involved teeth should be extracted, although this can be a challenging introduction to dental care for the young child. If numerous large lesions are present, they may be excavated and interim restorations placed. Use of glass ionomer cement, with its uoride release, oers some additional preventive benet. is “rst aid” approach reduces the chance of caries progression, with its resultant pain; reduces diculty in cleaning; and reduces deleterious oral ora. e introduction of silver diamine uoride can also be considered part of the dental armamentarium when addressing dentinal caries (see Chapter 12).26 For more denitive care, if teeth with deep lesions and chronic pulpal involvement are not painful, they can be incorporated in a treatment plan that proceeds by quadrant or sextant rather than being managed immediately.All factors being equal, restorative care often is easiest in the maxillary posterior areas. e inltration injections are easiest for patients to tolerate. e dentist can then move to the mandibular posterior sextants. Seldom are the mandibular anterior teeth involved unless rampant caries are present.Finally, the maxillary anterior teeth can be approached. is is a good nal selection because the injections are uncomfortable, and some families will not pursue all necessary care if the maxillary anterior teeth are restored rst with a good esthetic result.When restorative care is complete and the patient and parent demonstrate that they can maintain good oral health, orthodontic care, whether active or for space maintenance, can be considered. It is best if space maintenance can be implemented in the rst 6 months after necessary extractions because space loss is most common during this period (see Chapter 26).References1. American Academy of Pediatric Dentistry. Guideline on perinatal and infant oral health care. Academy of Pediatric Dentistry Council on Clinical Aairs. Pediatr Dent. 2016;38(6):150–154.2. American Academy of Pediatric Dentistry. Guidelines for record-keeping. Academy of Pediatric Dentistry Council on Clinical Aairs. Pediatr Dent. 2016;38(6):343–350. CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281.e1 Case Study: Examination and Treatment Planning in the 3- to 6-Year-Old PatientBhavna T. PahelA female, 5 years and 9 months old, named Genny comes to visit you for a comprehensive new patient exam. She is accompanied to the appointment by her mother. The family has recently moved to the area from out of state. Genny’s mother chose your practice because she saw excellent reviews on the internet and received high recommendations for your practice from her neighbors. She states that she is interested in establishing a dental home for Genny in your practice.Provide an overview of information you would obtain about Genny before you proceed with your dental clinical examination.A pictorial description of the recommended steps as part of a systematic new patient examination is provided in Fig. E19.1. As part of the medical history, Genny’s mother indicates she was born full term and there were no complications at birth. Genny has been vaccinated on schedule and her most recent tetanus toxoid was given last summer before she started kindergarten. Over the past year, Genny has developed exercise-induced asthma, triggered by running outside in cold weather. She uses an albuterol inhaler to control the symptoms. It is important for the clinician to review any positive responses on the medical history questionnaire with follow-up questions. In this case, upon further questioning, Genny’s mother reports the last time the inhaler was used was 4 months ago. She has not needed oral steroids nor visited the emergency room for asthma-related problems. Genny has no other medical problems or allergies. Regarding the social history, her mother states Genny is an only child and lives at home with both parents. Although Genny has never visited a dentist, her mother has used books and videos to prepare her for the dental visit today. According to her mother, Genny “bumped her two upper front teeth” approximately 1 month ago while playing on the sidewalk. Her mother had noticed some bleeding from the gums around the two upper front teeth which was self-limiting. Genny did not require treatment for that injury and she has not complained of discomfort in those teeth. Genny used to suck her left thumb at night, but the habit has stopped since she started kindergarten last year. The family eats a healthy diet with an abundance of fruits and vegetables, and Genny mainly drinks uoridated city water. Genny does have a sweet tooth and is allowed to eat gummy candies about once a week. According to her mother, it has been challenging to restrict her candy intake since she started kindergarten. Genny brushes her teeth twice a day using uoride toothpaste with occasional supervision from her mother or father, and she likes to oss her own teeth at night. There is no history of mouthwash use.You proceed with your clinical examination. Review Fig. E19.2 and describe what you see in a systematic manner.Extraoral ndings: Genny’s prole is convex with 33% lower face height. She has competent lips with mild protrusion of the upper lip. In the frontal view, Genny appears to be fairly symmetric with some straining of the lower lip. She has positive buccal corridors and good gingival display on smile.Intraoral soft tissue ndings: Soft tissues including, gingiva, frenula, tongue, and oral mucosa appear healthy, the oor of the mouth is well perfused, and the airway is Mallampati class I (Box E19.1).Intraoral hard tissue ndings: The patient is in the primary dentition. The primary buccal segments are intact, and no restorations or sealants are noted. Minimal plaque is noted on the lingual surfaces of the mandibular incisors and facial surfaces of the maxillary molars. Occlusion: (1) Anteroposterior—second primary molars are in mesial step occlusion and primary canines are in class I relationship bilaterally. The overjet is 3 mm; (2) Vertical—overbite is 80%; (3) Transverse—The midlines are coincident. Pathology: There is no clinical evidence of dental caries.Genny’s posterior contacts are closed so you proceed to obtain two bitewing radiographs (Fig. E19.3). Given a past history of trauma to the maxillary incisors, you also obtain a maxillary anterior periapical radiograph. Use a systematic approach to interpret the radiographs.The bitewings are of diagnostic quality and clearly show intact primary buccal segments on the right and left. The alveolar bone levels are within the range of normal. All four rst permanent molars (teeth #3, 14, 19, and 30) are evident on the radiograph. Incipient (enamel) caries is noted on the distal surface of tooth #S and the mesial surface of tooth #T. No other dental or bony pathology is noted. The maxillary anterior periapical radiograph Medical historySocial historyDental historyHabitsDietOral hygieneExtraoral findingsIntraoral findings- Soft tissues- Hard tissues- Posterior contacts open- History of dental trauma- Posterior contacts closed and/or- History of trauma presentNo radiographsTwo bitewings and/orperiapical radiographs- Preventive/maintenance- Growth and development- Restorative- BehaviorAssessment and plan• Figure E19.1 Overview of a systemic approach to a new patient clinical examination. Data from Samsoon GL, Young JR. Difcult tracheal intubation: a retrospective study. Anaesthesia. 1987;42(5):487–490.Class I—uvula, faucial pillars, and soft palate are visibleClass II—faucial pillars and soft palate are visibleClass III—soft palate is visibleClass IV—hard palate only is visible.Mallampati Classication• BOX E19.1 Continued 281.e2 Part 3 The Primary Dentition Years: Three to Six Yearsexhibits no dental or bony pathology, and all permanent incisors appear to be developing normally.Based on your parent interview and clinical examination, what is your assessment and plan to maximize Genny’s oral health?As depicted in Fig. E19.1, the comprehensive assessment and plan to maximize Genny’s oral health should include the four domains of: (1) preventive and maintenance plan; (2) growth and development; (3) restorative plan; and (4) behavior guidance plan. Given the presence of two proximal incipient caries lesions on teeth #S and #T, our focus should be on the rst domain of prevention and maintenance by improving oral hygiene practices and uoride exposure. The goal is to remineralize the incipient lesions. Genny’s parents should be encouraged to supervise brushing twice a day, and if Genny can spit reliably, an over-the-counter uoride mouthrinse can be added to the nightly oral hygiene regimen to increase topical uoride exposure. Diet modication to reduce candy consumption should also be a part of the preventive plan. The recall frequency can be more frequent at 3 rather than 6 months to allow for closer monitoring of oral hygiene and increasing exposure to topical uoride application in the dental ofce. Lastly, given the high caries risk, Genny may benet from sealants on the food retentive grooves of her primary molars. Her growth and development should be monitored at regular recall visits. Given her excellent behavior at the rst dental visit, all the preventive objectives likely can be achieved with standard behavior management techniques, including tell-show-do and positive reinforcement. All this information should be communicated to Genny’s mother in a compassionate manner to avoid parental feelings of guilt. It should be emphasized to the family that the dentist is a partner with them in achieving the best oral health for their child.Questions1. Why is it important to determine who the child lives with or who the child spends the most time with in a review of the child’s medical and social history?Answer: The clinician can determine several important factors in planning comprehensive care for this patient. The primary caregiver’s attitude toward general and oral health, the family’s dietary preferences, their access to uoridated water, as well as the level of oral hygiene supervision are just some of the factors determined in a review.2. In a comprehensive clinical exam, what are the three basic areas of examination? Why are these areas important for a dentist to examine?Answer: The three areas of a comprehensive clinical exam include an examination of (1) extraoral tissues; (2) intraoral soft tissues; and (3) intraoral hard tissues. Extraoral ndings such as facial asymmetry may provide clues as to the presence of trauma or infection. With respect to intraoral soft tissues, the presence of unexplained gingival bleeding may indicate the presence of a serious underlying medical condition such as a blood dyscrasia or leukemia. A thorough evaluation of intraoral hard tissues can provide important information regarding the patient’s occlusion, as well as any pathology, including developmental defects, trauma, and dental caries.• Figure E19.2 Extraoral and intraoral clinical photographs. CHAPTER 19 Examination, Diagnosis, and Treatment Planning 281.e3 3. Discuss the spectrum of behavior guidance strategies available to a dentist for a 3-year-old child in need of restorative treatment.Answer: The spectrum for treating a 3-year-old child in a safe and compassionate manner is immense. If the child exhibits cooperative behavior, basic behavior guidance strategies such as tell-show-do, positive reinforcement, and distraction, in combination with nitrous oxide/oxygen inhalation (as needed), may be effective in guiding the child’s behavior during the dental appointment. Conversely, if the child exhibits noncooperative behavior, the clinician can choose from a range of advanced behavior management strategies including protective stabilization, oral conscious sedation, and general anesthesia. The decision to use one or more of these behavior guidance strategies should be based, among other factors, on the child’s willingness and ability to cooperate, his or her medical history, and the amount of dental treatment required.• Figure E19.3 Maxillary anterior periapical and bitewing radiographs. 282 20 Prevention of Dental DiseaseARWA I. OWAIS AND ARTHUR J. NOWAKCHAPTER OUTLINEFluoride AdministrationDietary Fluoride SupplementationTopical Fluoride TherapyProfessional Applications of FluorideIndications for Professional Topical Fluoride ApplicationsCost-Benet ConsiderationsProphylaxis Before Topical Fluoride TreatmentMethod of ApplicationConsiderations for Special PatientsDietary ManagementDietary CounselingHome CareWith the eruption of all primary teeth, the preschool child enters a relatively short period of dental stability in preparation for the loss of the rst primary tooth and the lengthy process of eruption of the permanent teeth. Historically, many preschoolers’ rst dental examination occurred during this period; however, with the increased awareness that home care should be established much earlier for all children, a child might have already established a dental home by this age. During this stage, instructions are reinforced for appropriate oral hygiene techniques and topical uoride use. After taking into consideration the child’s caries risk, adjustments in optimal systemic uoride supplementation should be considered if the child is living in a nonuoridated community.Dietary management may now become a problem. is is the period of development of strong preferences for and aversions to specific foods. The effect of commercials from television, the Internet, and the press begins to take its toll. Children are frequently sent to a child care facility for a quasieducational experience, a babysitting service, or a true preschool developmental experience. Parental control of the quality and quantity of the diet is sometimes greatly sacriced due to the fact that other care providers are often involved in preparing meals and snacks for the children.When the end of the day is in sight and the children want to watch “just one more TV program,” or play “just one more game,” the daily supervised oral hygiene routine may be sacriced for the quick 30-second unsupervised brushing. It is amazing how quickly parents assume that 4-year-old children can be responsible for their own oral hygiene when they cannot even comb their hair or print their name clearly.Fluoride AdministrationDietary Fluoride SupplementationRecommendations on the prescription of dietary uoride supple-mentation for caries prevention were revised in 2013.1,2 Dietary uoride supplementation should be prescribed only for children who are at high risk of developing caries and whose primary source of drinking water is decient in uoride. erefore the rst step for the clinician is to determine if the child is at high caries risk as described in Chapters 14 and 15. If the child is at high risk for caries and drinks water that is decient in uoride, then uoride supplementation should be considered (Table 20.1).1,2e US Public Health Service (USPHS) currently recommends an optimal uoride concentration of 0.7 mg/L. is replaces the earlier USPHS recommendation for uoride concentrations of 0.7 to 1.2 mg which was based on outdoor air temperature of geographic areas.3 e new recommendation, which was supported by the American Dental Association (ADA), does not change the ADA Council on Scientic Aairs’ systematic review and clinical recom-mendation for the use of dietary uoride supplements that was released in 2010 (see Table 20.1).By 3 years of age, most children are able to chew and swallow tablets; therefore prescriptions for supplemental uoride should be changed from liquid drops to chewable tablets to reect this change in developmental status. e recommended supplemental uoride dosage schedule also requires an increase in the amount of uoride prescribed after a child reaches 3 years of age. e recommended daily dosage of supplemental uoride is 0.5 mg for children aged 3 to 6 years who drink water containing less than 0.3 ppm of uoride. e dosage is 0.25 mg for those whose water contains between 0.3 and 0.6 ppm uoride. Children whose drinking water contains more than 0.6 ppm of uoride do not require any supplementation. However, the potential for producing dental uorosis on permanent anterior teeth will have diminished in this age group owing to substantial crown formation (see Chapter 15 for details on uorosis). e practice of determining the uoride levels of each child’s drinking water before prescribing supplemental uoride should continue. In the United States, information on the uoride status of community water supplies, listed by state, county, and city, can be accessed on the Centers for Disease Control and Prevention (CDC) My Water Fluoride website (www.cdc.gov/oralhealth/).4 If the uoride level is unknown, then an analysis CHAPTER 20 Prevention of Dental Disease 283 applications are often applied during this interval, and their use should be based on caries risk assessment. One mode of topical application that is generally not recommended for the younger members of this age group is the use of uoride mouth rinses, because most preschoolers are unable to avoid swallowing some of these solutions.5Professional Applications of FluorideTopical application of highly concentrated forms of uoride has been provided in clinical settings for many years. ere is evidence that the use of 1.23% acidulated phosphate uoride (APF) and 5% sodium uoride varnish is eective in preventing dental caries in children 6 years and older. However, a recent report of the ADA Council of Scientic Aairs recommends only 2.26% uoride varnish (5% sodium uoride varnish) for children younger than 6 years because it does not have the risk of experiencing adverse events (particularly nausea and vomiting) associated with swallowing other forms of uoride.5 Fluoride varnish (Fig. 20.1) has become a popular topical agent for preschool children and individuals with special health care needs. It has been recommended for conditions can be requested from the local public health department, family dentist, or commercial laboratories.Because parental compliance continues to play a key role in determining the eectiveness of these supplements, eorts to reinforce parental motivation should be made. One method of assessing parental compliance is to monitor the need to rewrite supplemental uoride prescriptions at recall visits. e dosage of uoride prescribed should be noted in each patient’s record whenever a prescription is written. Parents who indicate no need for an additional prescription when the patient’s record suggests that the previously prescribed supplement should have been consumed should be questioned about the number of tablets remaining. A large remaining supply suggests poor compliance.Topical Fluoride TherapyTopical uorides have an increasingly important role in the 3- to 6-year-old group. e child’s ability to appropriately use uoride dentifrices increases throughout this period, although parental involvement at each brushing should continue. Professional topical The expert panel convened by the American Dental Association Council on Scientic Affairs developed the following recommendations. They are intended as a resource for dentists and other health care providers. The recommendations must be balanced with the practitioner’s professional judgment and the individual patient’s needs and preferences.Children are exposed to multiple sources of uoride. The expert panel encourages health care providers to evaluate all potential uoride sources and to conduct a caries risk assessment before prescribing uoride supplements.Recommendation Strength of RecommendationsFor children at low risk of developing caries, dietary uoride supplements are not recommended, and other sources of uoride should be considered as a caries-preventive interventionDFor children at high risk of developing caries, dietary uoride supplements are recommended according to the schedule presented in the next section of the tableDWhen uoride supplements are prescribed, they should be taken daily to maximize the caries-preventive benetDRecommended American Dental Association Dietary Fluoride Supplement Dosing Schedule for Children at High Risk of Developing CariesAgeAMOUNT OF FLUORIDE SUPPLEMENTATION AND STRENGTH OF RECOMMENDATIONS, ACCORDING TO FLUORIDE CONCENTRATION IN DRINKING WATER (PARTS PER MILLIONa)<0.3 0.3 TO 0.6 >0.6Fluoride SupplementationStrength of RecommendationsFluoride SupplementationStrength of RecommendationsFluoride SupplementationStrength of RecommendationsBirth to 6 months None D None D None D6 months to 3 years0.25 mg/d B None D None D3–6 years0.50 mg/d B 0.25 mg/d B None D6–16 years1.00 mg/d B 0.50 mg/d B None Da1.0 part per million = 1 milligram per liter.Strength of Recommendations: A, Directly based on category I evidence; B, directly based on category II evidence or extrapolated recommendation from category I evidence; C, directly based on category III evidence or extrapolated recommendation from category I or II evidence; D, directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence.From Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recommendations on the prescription of dietary uoride supplements for caries prevention. A report of the American Dental Association Council on Scientic Affairs. J Am Dent Assoc. 2010;141(12):1480–1489.Clinical Recommendations for the Use of Dietary Fluoride SupplementsTABLE 20.1 284 Part 3 The Primary Dentition Years: Three to Six YearsCost-Benet ConsiderationsIn a private practice setting, the patient’s willingness or ability to pay for dierent forms of treatment usually is an important factor in determining what types of services are provided. In the case of public programs or private third-party payers, the decision to provide reimbursement for various services may be based on a more formal analysis of the relationship between the costs and benets associated with those services. e ratio of costs to benets has historically been higher for topical uoride applications provided in dental oces than for other types of preventive services or for the same services provided in other settings. Consequently, professional topical uoride treatments have not been recom-mended as a public health measure because of their unfavorable cost-benet ratio.Documented changes in caries levels and patterns of decay in children in the United States have pushed these ratios even higher. Studies have reported that a substantial proportion of school-aged children in the United States are caries free and that a relatively small percentage of children account for a large percentage of all tooth decay.11 In addition to the overall decline in the level of caries, there has been a decrease in the proportion of smooth-surface caries and a corresponding increase in the proportion of pit and ssure caries. e combination of these factors seems to be associated with a reduction in the eectiveness of concentrated topical uoride therapy in terms of the actual number of surfaces saved from becoming carious during a given period.12Changes of this nature have led some interested parties to call for a reexamination of the manner in which various preventive measures are provided. In an era when increased attention is being focused on measures for controlling all types of health care costs, some have proposed that consideration be given to making preven-tive dental services more cost-eective. One means of improving the cost-benet ratio of topical uoride therapy would be to provide this therapy in settings other than dental oces, such as school-based programs and home use. In addition, cost-eectiveness may be enhanced by targeting those children at high risk for developing caries.A factor that has been repeatedly demonstrated to be associated with a reduction in both the risk of developing caries and the relative eectiveness of topical uoride therapy is the availability of drinking water containing uoride. Studies have shown that topical uorides are considerably more eective in reducing the incidence of decay in nonuoridated areas compared with uoridated areas.13 erefore the cost of preventing a carious lesion in a uo-ridated area by means of professional topical uoride therapy is signicantly greater than the cost of preventing a lesion in a nonuoridated area. is suggests that, in uoridated areas, topical uoride treatments should be reserved for patients who have a history of moderate to high caries development or who are in proven high-risk categories. ose who do not seem to be particu-larly prone to developing caries, especially smooth-surface decay, would probably benet more from other forms of prevention such as pit and ssure sealants. (See Chapter 33 for more details on pit and ssure sealants.)e question of which preventive services should be provided for a particular child in the dental oce remains an individual issue for dentists and their patients (or parents in the case of children). Accordingly, the nal decision about professional preven-tive services must be based on the child’s risk assessment and made by the child’s parents once informed on the costs and expected benets. However, the inuence of third-party coverage for dierent in which decalcied enamel secondary to poor plaque removal or poor feeding practices is present.6–8 A recent Cochrane review found that the application of uoride varnish two to four times a year is associated with a substantial reduction in caries increment.9 e American Academy of Pediatrics (AAP) has also endorsed the application of uoride varnish in children up to 5 years of age.In summary, the evidence-based approach to clinical recom-mendations should be integrated with the practitioner’s professional judgment and the patient’s needs and preferences.Indications for Professional Topical Fluoride ApplicationsWhen and for whom topical application of fluoride should be provided in the dental office has been a source of some controversy. One school of thought invokes the argument that professional uoride application is a primary preventive measure and should be provided to all children to minimize the potential for development of new carious lesions. Part of the historical basis for this approach relates to the lack of validated methods to predict whether an individual patient is likely to develop caries. Advocates of this philosophy tend to focus only on the potential benets that might be achieved from topical uoride application while ignoring the costs associated with providing the service.Others feel that the decision to provide topical uoride therapy should be based on the factors that have been shown to be associated with the risk of developing caries in groups or in individuals (e.g., access to uoridated drinking water, use of other forms of topical uoride, degree of spacing between teeth). eir approach is to consider the likelihood that each patient develops disease according to these caries risk factors and then to recommend professional topical uoride therapy for those considered to be at signicant risk for developing caries. Proponents of this philosophy tend to consider the costs associated with providing the service as well as the potential benets. Caries risk assessment methods are available to help clinicians predict with accuracy which individuals are more likely to develop caries and therefore would benet more from topical uoride therapy.10• Figure 20.1 Example of a uoride varnish. (Pictured: Vanish 5% sodium uoride varnish. Courtesy 3M Science Applied to Life Inc., USA.) CHAPTER 20 Prevention of Dental Disease 285 in both laboratory and clinical trials has shown that the ability of a variety of topical uoride agents to penetrate dental plaque and deposit uoride in the enamel is not signicantly reduced by the presence of an organic layer on the tooth surface. erefore there is no added benet from conducting prophylaxis prior to topical uoride application.14–17 On the other hand, prophylaxis is an excellent way to introduce children to the sensations associated with the use of a handpiece in the mouth. In addition, clean-ing the teeth before an examination makes for a more thorough assessment.Method of Applicatione most popular professional topical uoride agent currently in use for children up to age 6 years is 5% sodium uoride varnish types of services can signicantly aect this decision and ultimately the care received by the child.e recommendations for professionally applied topical uoride are that children 3 to 6 years of age should receive uoride varnish applications every 3 to 6 months. ose children with high caries risk should receive the treatments more frequently (i.e., every 3 months) (Table 20.2).5Prophylaxis Before Topical Fluoride TreatmentAnother issue related to the eectiveness of professional topical uoride therapy, which also has implications for lowering the cost-benet ratio, concerns the need for the prophylaxis that has traditionally been provided before uoride application. Research Evidenced-Based Clinical Recommendations for Professionally Applied Topical FluorideTABLE 20.2 Topical Fluoride AgentAGE GROUP OR DENTITION AFFECTED<6 Years (Primary Teeth)6–18 Years (Mixed Dentition)>18 Years (Permanent Teeth) Adult Root CariesEvery 3–6 months Every 3–6 months Every 3–6 months Every 3–6 monthsNot recommended Not recommended Not recommendedPanel unable to make recommendationNot recommendedmonths months monthsNot recommended Not recommendedNot recommendedPanel unable to make recommendationNot recommended Not recommendedNot recommendedPanel unable to make recommendationNot recommended Not recommendedNot recommendedPanel unable to make recommendationproducts (gel, paste)Not recommended Twice daily Twice daily Twice dailyNot recommended At least weeklyTwice daily Twice dailya Color Legend:Strong Evidence strongly supports providing this interventionIn Favor Evidence favors providing this interventionWeakEvidence suggests implementing this intervention only after alternatives have been consideredExpert Opinion ForbEvidence is lacking; the level of certainty is low. Expert opinion guides this recommendationExpert Opinion AgainstbEvidence is lacking; the level of certainty is low. Expert opinion suggests not implementing this interventionAgainst Evidence suggests not implementing this intervention discontinuing ineffective proceduresaDenitions for the strength of clinical recommendations adapted from the US Preventive Services Task Force (USPSTF) system.bThe USPSTF system denes this category of evidence as “insufcient”; “grade I indicated that the evidence is insufcient to determine the relationship between benets and harms (i.e., net benet).” The corresponding recommendation grade “I” is dened as follows: “The USPSTF concludes that the current evidence is insufcient to assess the balance of benets and harms of the service. Evidence is lacking, of poor quality, or conicting, and the balance of benets and harms cannot be determined.”APF, Acidulated phosphate uoride.Data from Weyant RJ, Tracy SL, Anselmo TT, et al. Topical uoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279–1291. 286 Part 3 The Primary Dentition Years: Three to Six Yearsdisabilities or medical conditions that either place them at higher risk for caries or limit their ability to obtain uoride in the usual manner. For example, uoride varnish can be applied quickly, requires minimal cooperation, and is more convenient to those who may nd it dicult to tolerate the trays used for other topical uoride applications.Another population of patients who require special consideration are those children being treated with irradiation or chemotherapy. ese patients often experience ulcerative degeneration of the soft tissues, causing them to be extremely sensitive to preparations having a low pH (i.e., APF) or to certain avoring agents. A diluted, neutral, nonirritating uoride formulation should be provided for these patients. In addition, children with chronic renal failure may experience elevated serum uoride levels for prolonged periods following ingestion of concentrated uoride preparations owing to their kidney impairment. Because they also have been noted to have a lower incidence of caries than matched controls, systemic or professional topical uorides are not recom-mended for these patients.18 It is up to the clinician to use the best method of topical uoride application that would be best for the individual patient.applied by primary health care providers. e ADA Council on Scientic Aairs recommends uoride varnish in young children due to the fact that it poses fewer side eects than other topical uoride products, because these children typically cannot expectorate properly.5 Less time is required to place the varnish, and therefore the treatment may be more cost-eective than the use of a uoride gel with trays.Advantages of sodium uoride varnish (see Fig. 20.1) include that it is easy to apply, in addition to being safe and eective. It can be applied by the primary care team and is covered by most insurance. A variety of 5% sodium uoride varnish preparations are commercially available. e unit dose of 0.25 mL 5% NaF is recommended for use in preschool children. e application technique is covered in Chapter 15.Considerations for Special PatientsAs in any age group, some children require special consideration with respect to their need for uoride therapy or the manner in which this therapy must be provided. Specically, alternative approaches should be available for children with developmental ADAPTIVE DAILY ORAL HYGIENE FOR THE CHILD WITH SPECIAL HEALTH CARE NEEDSGayle J. GilbaughGood oral health is an important aspect of every child’s well-being and general health. For the child with special needs, it is both a health and a social issue. Lack of regular home care can lead to dental disease causing a painful and unsightly mouth. This can interfere with daily functions such as eating, sleeping, and making friends. A child with special health care needs does not need this additional burden. A healthy smile boosts the child’s morale, enhances self-esteem, and is a part of total well-being.Unfortunately, daily oral hygiene can be a challenge for children with special health care needs and their caregivers. Some children with disabilities may be capable of cleaning their own teeth, whereas others may nd it physically and mentally difcult or impossible. In these cases a caregiver needs to provide some assistance.Daily oral hygiene should be built into the schedule and require a minimum of frustration for the child and caregiver. The basic tooth cleaning concepts are the same as for any child and should be accomplished daily. For the child with special health care needs, achieving the goals may require some adaptations and a little ingenuity.Historically there have not been many commercial oral care products that were tailored for people with special health care needs. However, nowadays a wide variety of cleaning devices, products, and adaptations are available for parents and caregivers, as shown in the second gure below. The following chart lists potential oral hygiene challenges and techniques or devices that may be of assistance while delivering care for individuals with special health care needs. All adaptations should be individualized according to the age and needs of a particular individual.Potential Obstacle Technique/DeviceAccess to the child • Avoidsmallconnedbathrooms• Usearoomwithplentyofspaceformaneuvering• GoodlightsourceDifculty expectorating • Usepea-sizedamountoftoothpaste CHAPTER 20 Prevention of Dental Disease 287 ContinuedADAPTIVE DAILY ORAL HYGIENE FOR THE CHILD WITH SPECIAL HEALTH CARE NEEDS—cont’dPotential Obstacle Technique/Device• Abulbsyringeorportablepowersuctioncanbeusedforexpectoration• Antimicrobialagentsanduoridecanbeappliedwithatoothbrush,cottonswab,orToothetteifindicated(Courtesy Sage Products, Cary, IL.)Excessive gagging (high gag reex)• Useatoothbrushwithasmallcompacthead• Useaminimalamountoftoothpaste• Avoidasupineposition,keeptheheadelevatedDry or chapped lips • Applypetroleumjellybeforebrushingorossing• BegentlewhenstretchingthelipsUnable to keep mouth open (hypertonic bite)• Useamouthprop• Commercialproductsareavailableorcanbefabricatedwithseveraltonguedepressorsandadhesivetape• PositionthemouthpropwithcaresothatthelipsarenotcaughtunderneathPerioral sensitivity • Desensitizingactivitiesconductedseveraltimesadaycanhelpthechildtotoleratethedailyoralhygieneregime• Consultwithaspeech-languagepathologistoroccupationaltherapist• MovementsshouldbeslowandgentleWheelchair bound • Standbehindthewheelchairforthebestviewintothemouth• Carefullyuseyourarmtosupportthepatient’sheadagainstyourbody• Sitbehindthewheelchairandlockthewheels• Tiltthechairintoyourlapanduseyourarmtosupportthepatient’sheadagainstyourbodyDifculty sitting up • Useafoamorbeanbagchairtostabilizethechild• Approachfrombehindandsupportthechild’sheadwithyourarm• Laythechildonthebedorsofawithhisorherheadinyourlap• Supportthechild’sheadandshoulderswithyourarm 288 Part 3 The Primary Dentition Years: Three to Six YearsADAPTIVE DAILY ORAL HYGIENE FOR THE CHILD WITH SPECIAL HEALTH CARE NEEDS—cont’dPotential Obstacle Technique/DeviceUncontrollable movements • Onecaregiver:havethechildsitontheoorbetweenthelegsofthecaregiversittingonthesofa.Theadultgentlyplaceshisorherlegsoverthechild’sarms.Or,havethechildlayontheoorwitharmsextended.Theadultsitsbehindthechild’sheadandgentlyplaceshisorherlegsoverthechild’sarms.• Twocaregivers:havethechildlayonthebedorsofawithhisorherheadonyourlap.Thesecondcaregivercanholdthechild’shandsorlegsifneeded.Difculty grasping toothbrush • Modifytoothbrushbyaddingalargerhandle(e.g.,rubberball,bicyclehandlegrip,ortennisball)• Commercialtoothbrusheswithalargehandleareavailable• Bendthetoothbrushhandleafterholdingunderhotwater• AttachaVelcrostraptothetoothbrushhandletosecurethetoothbrushinthehandLimited manual dexterity • PowertoothbrushFor additional information:•  National Institute of Dental and Craniofacial Research: www.nidcr.nih.gov/OralHealth/Topics/DevelopmentalDisabilities•  National Maternal & Child Oral Health Resource Center: www.mchoralhealth.org/•  www.mchoralhealth.org/PDFs/SHCNfactsheet.pdf•  Autism Speaks: www.autismspeaks.org•  Dental Professionals’ Tool Kit: www.autismspeaks.org/science/resources-programs/autism-treatment-network/tools-you-can-use/dental CHAPTER 20 Prevention of Dental Disease 289 Quantitative analyses showed a strong relationship between sugar intake and the progressive lifelong development of caries.19Although historically sucrose has been implicated as the major carbohydrate necessary for acid production, we now know that other simple carbohydrates can produce acid. is includes corn sweeteners which are commonly used in processed and convenience foods, as well as fructose and glucose which occur naturally in honey, fruits, and vegetables. erefore it is no longer simply a matter of recommending that the patient reduce his or her sucrose intake. Over the years, sucrose has been appreciably replaced in the food industry with fructose and other sweeteners. e critical factor that remains is the potential for these foods to produce acid that lowers the pH in and around the tooth in the presence of plaque. Many foods have been tested and found to lower the pH of the interproximal plaque to 5.5 or lower (Box 20.1).20Other critical cariogenic factors are the tendency of a food to adhere to the teeth, the rate at which a food dissolves, the potential for a food to stimulate saliva production, and the potential for a food to buer the production of acid. It has been suggested that a food with a low cariogenic potential would have the following attributes20:1. A relatively high protein content2. A moderate fat content to facilitate oral clearance3. A minimal concentration of fermentable carbohydrates4. A strong buering capacity5. A high mineral content, especially of calcium and phosphorus6. A pH greater than 6.07. e ability to stimulate saliva owFoods with “lower cariogenic potential” should be suggested to parents. At the same time, it is important to educate them to adhere to the required calorie intake of the young child.Dietary CounselingAlthough the dental profession recognizes the role of good nutrition and appropriate dietary practices in achieving and maintaining good oral health, promoting behavioral changes has been chal-lenging. Fortunately, parents are now more aware of these issues and willing to listen, and many are even ready to make changes. Dietary ManagementA number of factors begin to emerge during the preschool period that can have a profound eect on the growth and development of children, as well as on their dental health. Following the large gains in growth during the rst 3 years of life, the preschool child’s rate of growth slows markedly. erefore caloric requirements should be reduced accordingly, but a balanced diet need not be sacriced. Because it is becoming common for both parents to be employed when a child reaches the age of 3 years, the management and control of the child’s diet that had been maintained during the rst 3 years of life may become threatened. When preschoolers are sent o to a babysitter, grandparents, or day care center, children are introduced to new environments, food selections, and manage-ment styles. It is no wonder that they become confused, begin to question routine dietary practices, and even stop eating foods that were once favorites.By this time, they begin to be aected by what they see on television. e preschooler may be exposed to 2 to 8 (or more) hours of television on any day. Advertisements during this period are numerous, and unfortunately most are for food items, all of which the preschooler seems to want when he or she accompanies the parents to the market for the shopping.Fortunately, children at this stage are still willing to try new foods. Parents need to experiment not only with new foods but also with the preparation of these foods. In addition, the presentation of foods is important. Appropriate amounts of a variety of colorful foods go a long way to increasing children’s consumption at mealtime.Although preschoolers seem to always be busy, they have an increasing amount of “idle” time because of their decreasing willing-ness to take a morning or afternoon nap. With more awake time available, snacking often increases as a reection of comments heard on television, and the encouragement of peers. Appropriate snacking should be encouraged. Snacks heavy with salt, fats, or rened carbohydrates of a consistency that adheres to the teeth and oral tissues or dissolves slowly are more likely to lead to dental problems. Teachers and caretakers must be educated or told by parents or guardians about the kinds of snacks that are best for their children. On special occasions, such as birthday parties, Halloween, or Valentine’s Day, a special treat of sweets can be allowed. At all other times, snacks should be selected from a list of foods that have been shown to be “friendly to teeth.”Fortunately, preschoolers are highly impressionable and can be greatly inuenced by experiences within the family. erefore mealtimes are important “classrooms” in which they learn and observe the feeding practices of older siblings and their parents. A friendly, congenial atmosphere at mealtime without threats (“You’d better eat all your food or you’ll get no dessert”) or badgering from siblings goes a long way toward establishing positive dietary practices.It is because of these factors that the dentist may nd it dicult to encourage parents to modify dietary practices when they are implicated in dental disease. Although many approaches are available to the dental team, no one approach is successful all the time. e approach used must be individualized to the personality of the practice, the willingness of the family to learn, and the specic dental problems encountered. Although caries is a multifactorial disease, it is essential to acknowledge that dietary sugars are the most important factor in causing this disease. Sugars provide a substrate for cariogenic oral bacterial to ourish and to generate enamel-demineralizing acids, consequently causing caries. Apples, driedApples, freshApple drinkApricots, driedBananasBeans, bakedBeans, green cannedWhite breadWhole wheat breadCaramelsCooked carrotsCereals, presweetened and regularChocolate milkColaCrackers, sodaCream cheeseDoughnutsGelatin-avored dessertGrapesMilk, wholeMilk, 2%OatmealOrangesOrange juicePastaPeanut butterPotato, boiledPotato chipsRaisinsRiceSponge cake, cream-lledTomato, freshWheat akesFoods That Cause the pH of Interproximal Plaque to Fall Below 5.5• BOX 20.1 290 Part 3 The Primary Dentition Years: Three to Six Years• Figure 20.2 The US Department of Agriculture’s newly released food guide, MyPlate. (Courtesy US Department of Agriculture.)If the child has a disability, additional questions are indicated:1. What dietary practices are modied because of the child’s disability?2. Are there additional nutritional requirements because of the disability?3. Does the child feed herself or himself, or does she or he require assistance?4. What medications are taken by mouth, and how often are they taken?5. Does the child have diculty with chewing and swallowing?6. Does the child hold (ruminate) food in his or her mouth for long periods? Does he or she regurgitate food?By being familiar with the 2015 to 2020 Dietary Guidelines and the answers to these questions, the dentist and sta should have the basic background information on the nutritional require-ments and dietary practices of the patient and his or her family. e 2015 to 2020 Dietary Guidelines provides ve overarching guidelines including:1. Follow a healthy eating pattern across the lifespan.2. Focus on variety, nutrient density, and amount.3. Limit calories from added sugars and saturated fats and reduce sodium intake.4. Shift to healthier food and beverage choices.5. Support healthy eating patterns for all.In families with a preschool child who has no dental disease and evidence of sound dietary management, a word of positive reinforcement from the dentist is indicated. Dietary histories and counseling would seem to be counterproductive in this situation.In families with preschool children who have caries or appear to be at high risk for caries, further assessment by the dentist is indicated. A dietary history should be obtained, from either the parent’s recollection of the previous 24 hours or a written record of the next 3 to 7 days. Although the reliability of dietary histories is often questioned, in a spirit of trust and respect much can be learned.Many dietary history forms are available commercially, or they can be easily made. Parents should be instructed on how to complete the history, making sure to list all foods eaten by the child at each meal, the amounts eaten, the types and quantities of food consumed between meals, and the liquid intake. Dietary or vitamin supple-ments and oral medications should also be listed.Although the primary purpose of the dietary assessment in the dental oce is to identify dietary patterns that are or may be potentially deleterious to oral health, the dentist should be aware of dietary intake and patterns that may greatly inuence overall growth and development. In cases where diet-related problems are noted, the children should be referred for further assessment and counseling by a primary health care provider, dietician, or nutritionist.With the dietary history available, the dentist can review the ndings alone or with the parent:1. How many times a day does the child eat?2. Is there a diversied selection of foods? Are the meals well balanced?3. Are recommendations regarding the four basic food groups being satised daily?4. What is the frequency of snacking?5. Are foods high in (rened) carbohydrates consumed frequently? Are they consumed during, after, or between meals?6. Are snack foods of the kind that dissolve slowly or that adhere to the teeth?Some excellent resources that provide information for families’ nutritional requirements include the World Health Organization’s e WHO Guideline: Sugars Intake for Adults and Children21 pre-sented in six languages, the 2015 to 202022 Dietary Guidelines for Americans, 2015 to 2020, and the preschoolers section in the MyPlate (Fig. 20.2).23 ese resources provide parents with practical information on eating and physical activity patterns that are focused on consuming fewer calories, making informed food choices, and being physically active to attain and maintain healthy weight, reduce risk of chronic disease, and promote overall health.In families with a preschool child and no dental disease, the approach would be quite dierent from that recommended for families with a preschool child with dental disease. For all children the dentist should ask the parents the following questions during the initial interview to develop a baseline for further dietary assessment:1. At what age was the child weaned from the breast or bottle?2. If the child was still on the breast or bottle after 1 year of age, what was the frequency and duration of use?3. When were solids introduced?4. Were baby foods commercially prepared or homemade?5. How many meals are served presently? Does the family eat together?6. Who selects the menu and prepares the food?7. Are snacks provided? Are they given at home, in nursery school, or by a babysitter? As a parent, do you choose the snacks? If not, do you know what they are?8. Is the child a good eater? Does he or she eat a balanced diet? If not, what are the problem areas?9. Does the child have any grandparents living at home? Or does the child spend appreciable time at the grandparents’ home?10. Are there any religious or ethnic preferences that would limit dietary choices?11. What is the source of the water used for drinking and prepara-tion of foods?12. What is the child’s daily liquid intake? How much of that liquid is derived from drinking water in your community?13. How much time does the child spend daily watching television or in front of the computer/electronic devices?14. How much play/physical activity does the child have daily? CHAPTER 20 Prevention of Dental Disease 291 in this age group, parents must remain involved. e attention span of a typical 3- to 6-year-old is short, and with at least 100 surfaces on primary teeth to clean, they require parental assis-tance and supervision. Power toothbrushes have been shown to be as eective as manual toothbrushes and have the additional feature of being fun to use (Fig. 20.3). erefore compliance is greatly increased.24Application of a uoride-containing dentifrice is recommended, although with parental supervision. A pea-sized amount of dentifrice should be placed on the brush and the child should be instructed to expectorate once brushing is completed. Larger amounts of dentifrice are not indicated. Studies have shown that preschoolers often swallow large amounts of dentifrice, which may contribute to development of uorosis.25 It is recommended that oral hygiene care should be performed regularly after meals. When circumstances prevent this, a thorough swishing of the mouth with water is recom-mended. At bedtime, oral hygiene is especially important because of the reduction in saliva production at night with an increase in acid production.Toward the end of this period the preschool child begins to lose the primary teeth. The areas of exfoliation may be painful and the gingiva may be swollen, leading to discomfort. During these times the parent must maintain the oral hygiene habits to eliminate additional inammation around exfoliating teeth.Children with disabilities may require additional assistance because daily home care can be more challenging. Parents or caregivers should establish a daily routine because many individuals with special health care needs do best with routines. Allowing the child to hold a favorite item may have a calming eect. Encourage the parents to give verbal reassurance and brush in a slow, calm manner.Depending on the disability and its severity, various positioning methods may be helpful for increasing visibility into the mouth and reducing excessive movement. For individuals with special health care needs incapable of independent brushing, the caregiver should take on that responsibility. See the “Adaptive Daily Oral Hygiene for the Child with Special Health Care Needs” box for additional adaptive strategies and techniques.After the problem areas have been identied, recommendations can be oered. Sweeping modications of the family diet and dietary practices will be met with resentment, poor compliance, and negative results. A better approach would be to select one problem area, make a recommendation for change, wait a few weeks, and then evaluate the results. If results are positive, another area can be modified, and the family can then build on its successes.Follow-up histories are indicated depending on the oral health status. Dietary counseling is only part of a comprehensive preventive program, although at times it is the most obvious area in need of adjustment. It can also be the most dicult area in which to obtain success.A number of electronic nutrition analysis programs are avail-able through the Internet. After a dietary history is entered, a number of analyses become available, including meal planning and recommendations for physical activity. To date, none is specic for evaluating diets that may contribute to oral disease in children.Home CareWith the changes in the child’s knowledge base, socialization, and maturation in growth and development taking place during this period, daily home care should be less dicult. Unfortunately, that usually is not the case. Parents tend to assume that their child can be more independent than he or she actually is. ey also assume that the child’s motor coordination has progressed to a point where adequate manipulation of a toothbrush and oss is within reach. Meanwhile, children at this age want to be indepen-dent; they like to brush their teeth themselves and do not want help from Mom and Dad.A negotiated settlement has to be reached. For example, after meals the child can brush the teeth with minimal or no supervi-sion, but at bedtime the parents will clean the teeth and massage the gums. Working together as a team, the parent and child can each carry out their identied responsibilities, developing a suc-cessful program that can be further monitored and modied by the dentist.During this period, all the primary teeth are present. Spaces that were visible earlier may begin to close. Cleaning the mouth includes brushing the teeth, cleaning the tongue, and massaging the gingiva. is is a ne motor activity that most 3 to 6 year olds cannot perform completely without assistance. In addition, the lingual surfaces of the mandibular posterior teeth and the buccal surfaces of the maxillary posterior teeth are the most dicult to reach and to see if all the plaque has been removed.As spaces are closing, the use of dental oss is indicated. Children from 3 to 6 years of age are unable to oss. Parents should be responsible for this activity. Care should be taken not to snap the oss into the interproximal gingiva, causing injury. Results of this injury may make the child less receptive to any oral hygiene procedures, including toothbrushing.Visibility and accessibility can be greatly enhanced by correct positioning. Although most preschoolers want to stand at the sink, this is a dicult position from which parents can assist comfortably. Placing the child in a supine position periodically to improve visibility is recommended.ere are many improved designs in both manual and power toothbrushes. Parents have a large number of products from which to select. Sizes, shapes, colors, timers, and motivational characters are widely available from all manufacturers. Nevertheless, • Figure 20.3 Examples of battery-powered toothbrushes designed for children ages 2 to 5 years. The brush features a popular character, which encourages brushing. 292 Part 3 The Primary Dentition Years: Three to Six YearsReferences1. American Academy of Pediatric Dentistry. Guideline on uoride therapy. Pediatr Dent. 2016;38(special issue):181–184.2. Rozier RG, Adair S, Graham F, et al. Evidence-based clinical recom-mendations on the prescription of dietary uoride supplements for caries prevention. A report of the American Dental Association Council on Scientic Aairs. J Am Dent Assoc. 2010;141(12):1480–1489.3. Briss P, Bailey W, Barker LK, et al. U.S. Public Health Service recom-mendation for uoride concentration in drinking water for the preven-tion of dental caries. Public Health Rep. 2015;130(4):318–331.4. Division of Oral Health. My Water’s Fluoride Web Application. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2016. http://www.cdc.gov/oralhealth/. Accessed August 7, 2017.5. Weyant RJ, Tracy SL, Anselmo TT, et al. Topical uoride for caries prevention: executive summary of the updated clinical recommenda-tions and supporting systematic review. J Am Dent Assoc. 2013;144(11):1279–1291.6. Seppa L, Leppönen T, Hausen H. Fluoride varnish versus acidulated phosphate fluoride gel: a 3-year clinical trial. Caries Res. 1995;28:327–330.7. Weinstein P, Domoto P, Koday M, et al. Results of a promising open trial to prevent baby bottle tooth decay: a uoride varnish study. ASDC J Dent Child. 1994;61:338–341.8. Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride varnish ecacy in preventing early childhood caries. J Dent Res. 2006;85:172–176.9. Marinho VCC, Worthington HV, Walsh T, et al. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013;(7):CD002279.10. American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(special issue):142–149.11. Dye A, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248): 1–92.12. Ripa LW. Professionally (operator) applied topical uoride therapy: a critique. Int Dent J. 1981;31(2):105–120.13. Centers for Disease Control and Prevention. Recommendations for using uoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50(RR–14):1–42.14. Ripa LW, Leske GS, Sposato A, et al. Eect of prior tooth cleaning on bi-annual professional acidulated phosphate uoride topical uoride gel-tray treatments. Results after three years. Caries Res. 1984;18: 457–464.15. Johnston DW, Lewis DW. ree-year randomized trial of professionally applied topical uoride gel comparing annual and biannual applications with/without prior prophylaxis. Caries Res. 1995;29(5):331–336.16. Houpt M, Koenigsberg S, Shey Z. e eect of prior toothcleaning on the ecacy of topical uoride treatment. Two-year results. Clin Prev Dent. 1983;5(4):8–10.17. American Academy of Pediatric Dentistry. Guideline on the role of dental prophylaxis in pediatric dentistry. Pediatr Dent. 2011;33(special issue):151–152.18. Crall JJ, Nowak AJ. Clinical uses of uoride for the special patient. In: Wei SHY, ed. Clinical Uses of Fluorides. Philadelphia: Lea & Febiger; 1985:193–201.19. Sheiham A, James WP. Diet and dental caries: the pivotal role of free sugars reemphasized. J Dent Res. 2015;94(10):1341–1347.20. Schachtele CF, Jensen ME. Can foods be ranked according to their cariogenic potential? In: Guggenheim B, ed. Cariology Today. Basel: Karger; 1984:136–146.21. World Health Organization (WHO). Guideline: Sugars Intake for Adults and Children. Geneva: WHO; 2015.22. U.S. Department of Health and Human Services. Oce of Disease Prevention and Health Promotion. Dietary guidelines; 2017. www.dietaryguidelines.gov. Accessed August 7, 2017.23. U.S. Department of Agriculture. MyPlate, 2017. www.choosemyplate .gov. Accessed August 7, 2017.24. Nowak AJ, Skotowski MC, Cugini M, et al. A practice based study of a children’s power toothbrush: ecacy and acceptance. Compend Contin Educ Dent. 2002;23:25–32.25. Levy SL, McGrady JA, Bhuridej P, et al. Factors aecting dentifrice use and ingestion among a sample of U.S. preschoolers. Pediatr Dent. 2000;22:389–394. CHAPTER 20 Prevention of Dental Disease 292.e1 Case Study: Fluoride ToxicitySujatha S. SivaramanFluoride supplementation of community water for the prevention of dental caries has been widely used since 1946.1 The current recommended level is 0.7 ppm uoride.2 Over the years the success of community water uoridation has led to the development of other modes of uoride supplementation such as uoride-containing toothpaste, mouthrinse, topical gel, foam, and varnish. It is important for both professionals and caregivers to be aware of the concentration of uoride in the products their patients/children may be using. These concentrations are included in Table E20.1.An average uoride ingestion of 0.034 mg/kg/day was found among 2-year-old children in a study conducted in the Midwest region of the United States. The daily uoride ingestion from foods and beverages varied from nondetectable to more than 3.0 µg.3 Common childhood foods that naturally contain high levels of uoride include grape juice, spinach, carrots, orange juice, beets, raisins, and cereals containing oats and wheat. Therefore it is important that medical and dental providers consider a child’s diet before prescribing uoride supplements to prevent uorosis.Accidental or intentional ingestion of excessive amounts of uoride containing products (e.g., toothpastes, mouthrinses, and uoride tablets) can lead to acute or chronic toxicity.4 Acute uoride toxicity can cause a sudden onset of nausea, abdominal pain, vomiting and diarrhea, cytotoxic effects, hyperkalemia, seizures, and multiple organ failure, which can be fatal (Fig. E20.1).5 This acute toxicity occurs when an individual ingests a high dose of uoride in a short span of time. The severity of toxicity depends on the dose of uoride exposure, as listed in Table E20.2.The response for acute uoride toxicity is immediate transport to an emergency department and measures that minimize gastrointestinal absorption, increase urinary output, and maintain stable vital signs.5 Treatment includes:• Inducevomitingifithasnotoccurred• Give1%calciumchloride/gluconateortoleratedlevelsofmilkorally• InformemergencydepartmentpersonnelaboutpotentialuoridetoxicityFor life-threatening toxicity, the management at an emergency department may include5:• Intravenous(IV)placementandairwaymaintenance• Electrocardiogrammonitoring• Labsforserumuoridelevels,bloodpHandgases,andelectrolyteandglucose levels• IVcalciumgluconatetopreventhyperkalemiaandsodiumbicarbonatetominimize acidosis.In severe cases, respiratory support, cardioversion, and hemodialysis may be required.5Prevention is key when addressing uoride toxicity among children. Suggested preventive measures include child-resistant caps on uoride mouthrinses and supplement containers, warning labels on toothpaste, supervised use of uoride products, and familiarity with symptoms of uoride toxicity.5Form of Fluoride Fluoride Concentration Frequency Indications ContraindicationsToothpaste 1000 ppm of NaFRice or smear size (0.1 mg uoride) if <3 yearsPea size (0.25 mg uoride) from 3–6 years of age6Twice a day Initiate at eruption of rst toothNonePrescription toothpaste1.1% NaF-5000 ppm uoride7Once a day High caries–risk childrenChild should be able to expectorate and not be at risk of major uorosisLow-risk children and children <6 years of ageSupplements Available as drops or tablets (0.25, 0.5, 1.0 mg)7Once a day Fluoride exposure <0.6 ppmChildren <6 months of ageChildren receiving adequate uoride from other sourcesMouthrinse0.2% NaF-900 ppm uoride7Twice a day High caries–risk patients Children <6 years of age or children who cannot expectorateTopical gels Acidulated phosphate uoride - 1.23%-12,300 ppm uorideEvery 3 months in primary and mixed dentition or twice a year for root cariesHigh caries–risk patients Low-risk patientsChildren who cannot expectorate into a saliva ejectorVarnish5% NaF varnish-22,500 ppm uorideAs soon as tooth eruptsUp to four times a yearHigh caries–risk patients Low caries–risk patientsFluoride ProductsTABLE E20.1 Toxic Effects of FluorideDose of Fluoride Exposure in ChildrenOnset of symptoms 3 mg/kgToxic dose 5 mg/kgLethal dose 16 mg/kgData from LyJ,ShinRD,Miller MA, etal. Fluoridetoxicity.http://emedicine.medscape.com/article/814774-overview.AccessedSeptember12,2017.Degrees of Fluoride Toxicity in ChildrenTABLE E20.2 Continued 292.e2 Part 3 The Primary Dentition Years: Three to Six YearsQuestions1. What is the recommended level of uoride in water uoridation?Answer: 0.7 ppm uoride2. What should be taken into consideration before prescribing uoride supplements to children?Answer: The daily uoride ingestion from foods and beverages varied from nondetectable to more than 3.0 µg. Common childhood foods that naturally contain high levels of uoride include grape juice, spinach, carrots, orange juice, beets, raisins, and cereals containing oats and wheat. Therefore it is important that medical and dental providers consider a child’s diet before prescribing uoride supplements to prevent uorosis.3. What is the recommended amount of toothpaste for young children?Answer: Rice or smear size (0.1 mg uoride) if below 3 years of age; pea size (0.25 mg uoride) from 3 to 6 years of age.4. What are some recommended preventive measures to prevent accidental uoride ingestion at home?Answer: Suggested preventive measures include child-resistant caps on uoride mouthrinses and supplement containers, warning labels on toothpaste, supervised use of uoride products, and familiarity with symptoms of uoride toxicity.References1. American Dental Association. 5 reasons why uoride in water is good for communities.http://www.ada.org/en/public-programs/advocating-for -the-public/uoride-and-uoridation/5-reasons-why-uoride-in-water-is-good-for-communities. Accessed September 12, 2017.2. U.S. Department of Health and Human Services Federal panel on Community Water Fluoridation. U.S. Public Health Service Recommendation for Fluoride Concentration in Drinking Water for the Prevention of Dental Caries. Public Health Rep. 2015;130(4):318–331.3. Martinez-MierE,SpencerK,SandersB,etal.Fluorideinthedietof2-years-old children. Community Dent Oral Epidemiol. 2017;45(3):251–257.4. LyJ,ShinRD,MillerMA,etal.Fluoridetoxicity.http://emedicine.medscape.com/article/814774-overview.AccessedSeptember12,2017.5. Whitford G. Acute toxicity of ingested uoride. Monogr Oral Sci. 2011;22:66–80.6. American Dental Association Council on Scientic Affairs. Fluoride toothpaste use for young children. J Am Dent Assoc. 2014;145(2):190–191.7. American Academy of Pediatric Dentistry. Guideline on uoride therapy. Pediatric Dent. 2016;38(special issue):181–183.DeathOrgan failureSeizure activityCytotoxicityElectrolyte imbalanceNausea, vomiting, diarrhea• Figure E20.1 Schematic representation of acute uoride toxicity. 29321 Dental MaterialsKEVIN J. DONLY AND ISSA S. SASACHAPTER OUTLINEBases and LinersCalcium HydroxideZinc Oxide–EugenolGlass Ionomer CementDentin-Bonding AgentsRestorative MaterialsAmalgamResin-Based CompositeBulk-Fill ResinsGlass IonomerCompomersCementsMonolithic Zirconiasalicylate to form an amorphous calcium disalicylate. e alkaline pH aids in preventing bacterial invasion. Studies have shown that calcium hydroxide “softens” under amalgam and resin-based composite restorations.1,2 e results are attributed to hydrolysis of the calcium hydroxide by uid contamination from dentinal tubules and microleakage. As hydrolysis occurs, occlusal forces cause apical displacement of the restoration, leading to discrepancies and breakdown at the restoration margin. Visible light–cured calcium hydroxide preparations have demonstrated clinical success3 and may be less susceptible to hydrolysis. When calcium hydroxide is used, a less soluble high-strength base material such as glass ionomer may be placed to overlie the calcium hydroxide.Zinc Oxide–EugenolZinc oxide–eugenol cement (Fig. 21.2) contains zinc oxide, rosin, and zinc acetate in the powder. e rosin increases fracture resistance and the zinc acetate is eective in accelerating the reaction rate. e liquid is a preparation of eugenol, which reacts with the powder to form an amorphous chelate of zinc eugenolate. The zinc oxide–eugenol cements are used to provide a sedative eect in deep preparations, but their low compressive strength presents clinical limitations.To strengthen zinc oxide–eugenol cements, acrylic resin and alumina reinforcers have been added. Although these cements are stronger, they remain weaker than the zinc phosphate and glass ionomer cements. When it was evaluated as a base, zinc oxide–eugenol demonstrated signicant microleakage in comparison with glass ionomer cement.4 Because of its sedative eects and years of clinical success, zinc oxide–eugenol remains the material of choice for the pulp chamber lling material following pulpotomies or pulpectomies in the primary dentition. Zinc oxide–eugenol cements should be used with caution under resin-based composite restora-tions because the eugenol can inhibit the polymerization of the resin. A glass ionomer cement base may be placed over zinc oxide–eugenol before the placement of resin-based composite in order to avoid polymerization.Glass Ionomer CementGlass ionomer cement (Fig. 21.3) has become a commonly used basing agent. It has the ability to create a physicochemical bond to tooth structure and to release uoride. Glass ionomer cement consists of calcium aluminosilicate glass particles mixed with polyacrylic acid. e initial reaction stage involves the ionization of polyacrylic acid, which leads to a change in the polymer chains from a coiled to a linear form. e hydrogen ions produced by Restorative materials used in pediatric restorative dentistry are commonly the same as those used in restorative dentistry in general. is chapter identies commonly used materials in pediatric dentistry and provides information that applies speci-cally to their use. Many materials are available, and in many cases clinical considerations will dictate the choice of the appropriate material. Table 21.1 identies the most commonly used materials in pediatric restorative dentistry and the relevant clinical consid-erations. Chapters 22, 33, and 40 discuss the specic clinical restorative techniques associated with these restorative materials.Bases and Linerse use of bases and liners is important in pediatric dentistry. Bases and liners are available to reduce marginal microleakage from the restoration and prevent sensitivity to the underlying tooth structure. Traditionally, preparations of calcium hydroxide, zinc oxide–eugenol, and zinc phosphate were the materials of choice. Currently, glass ionomer cement is also a common base.Calcium HydroxideCalcium hydroxide cements are supplied in a visible light–cured system (Fig. 21.1A) and a two-paste system (Fig. 21.1B). A catalyst paste containing calcium hydroxide, zinc oxide, and zinc stearate in ethylene toluene sulfonamide reacts with a base paste containing calcium tungstate, calcium phosphate, and zinc oxide in glycol 294 Part 3 The Primary Dentition Years: Three to Six YearsMaterials Types Available Composition Clinical ConsiderationsIntermediary basesCalcium hydroxideZinc oxide–eugenolaThin pastes of calcium hydroxide or zinc oxide and eugenol suspended in resinsPlaced on small areas of cavity preparation deeper than ideal depthPlaced on exposed dentin of preparations undergoing acid etchingUsed for direct pulp capping of permanent teethMust not be left on enamel of preparationsAmalgam Lathe-cutSphericalAdmixedUnicompositionalaSilver (40%–74%)Tin (25%–30%)Copper (2%–30%)Zinc (0%–2%)Mercury (0%–3%)A high copper (>6%) admixed or unicompositional, precapsulated alloy is recommended for restoration of pit and ssure and interproximal caries in posterior teethStainless steel crownsStraight sidesPrecontouredaPretrimmedaIron (65%–73%)Chromium (17%–20%)Nickel (8%–13%)Manganese, silicon, and carbon (<2%)Restoration of badly broken down teeth, usually posterior, must be well trimmed, contoured, polished, and cemented to ensure optimum gingival healthFilled resin-based composite(Based on ller size)Traditional, 5–30 µmMicroll, 0.04–1 µmaHybrids, 0.04–100 µma (available as auto-cure or visible light–activated)aDimethacrylate (Bis-GMA) resin or urethane matrix with ller particles of quartz, silicates, or glassEsthetic restoration of anterior teethAvailable for use in class I and II restorations in posterior teethMicrolls provide most polishable surfaces and have excellent estheticsHybrids demonstrate least shrinkage and wear and have good polishability and estheticsVisible light activation provides better polymerization control, better color stability, and less porosity than auto-polymerized resinsCements Glass ionomeraSilicate glass containing Ca, Al, F, polycarboxylic acidPrimary use is cementation of stainless steel crownsMay be used as a baseGlass ionomer may be used as a liner for resins and conservative restorations in primary teethReinforced zinc oxide and eugenol most frequently used for obliterating primary pulp chambers following pulpotomyReinforced zinc oxide and eugenolaZinc oxide reinforced with alumina, polymer, or eugenolZinc oxide–eugenol Zinc oxide, eugenolaTypes most frequently used.Commonly Used Biomaterials in Pediatric DentistryTABLE 21.1 AB• Figure 21.1 Calcium hydroxide cements. (A) Visible light–cured system (Dycal). (B) Two-paste system (Prisma VLC Dycal). (Courtesy DENTSPLY Caulk, Milford, DE.) CHAPTER 21 Dental Materials 295 phosphate ions. Some manufacturers recommend removing the smear layer, created during cavity preparation, with polyacrylic acid. is tooth “conditioning” provides an uncontaminated tooth surface for bonding. Because the setting reaction requires some moisture, it is critical not to desiccate the tooth after rinsing conditioning from the preparation.Tartaric acid is added to the glass ionomer cement to accelerate the rate of hardening without decreasing the working time. Itaconic acid may be placed in glass ionomer mixtures to increase the reactivity of the polyacrylic acid to the glass, and polymaleic acid may be added to modify the reaction.Studies have shown that glass ionomer bases and liners exhibit less marginal microleakage than zinc oxide–eugenol, zinc phosphate, and calcium hydroxide,4,5 thereby preventing bacterial penetration. Fluoride is released from glass ionomer cement by dissolution and diusion. Glass ionomer bases and liners have demonstrated the inhibition of secondary caries formation.6–9 e uoride released is taken up by both the enamel and dentin adjacent to the material.10–13 is uoride aids in creating an inhibition zone that is not susceptible to demineralization, when compared with areas adjacent to non–uoride-releasing materials.14,15Glass ionomer cements are supplied in anhydrous and hydrous forms. Due to the viscosity of the hydrous form, mixing the cement may be dicult. e anhydrous form has a longer shelf life because the polyacrylic acid is dehydrated and placed in the powder. It is critical that glass ionomer be mixed according to the manufacturer’s instructions. If the cement is too thick it will not provide sucient water to complete the reaction, and dentin sensitivity may be encountered; the necessary water will be obtained from the dentin, causing sensitivity due to hydraulic pressures created within the dentin.Resin-modied glass ionomer cement preparations are available and can be light-cured.16 Photoinitiated polymers have been placed in the glass ionomer cement formulation to provide light poly-merization. Although these resin-modied glass ionomer cements can be light-cured, the material sets as a true cement, with an acid-base reaction taking place; therefore, given enough time, the material will chemically set without light curing.Glass ionomer cement has a coecient of thermal expansion similar to that of tooth structure; it can protect an underlying base and dentin, bonds to resin-based composite, and releases uoride, which can inhibit secondary decay.Dentin-Bonding AgentsDentin-bonding agents have been incorporated into the restorative dentistry armamentarium. Previously, dentin- or enamel-bonding agents fell into two groups. e rst was halophosphorus esters of 2,2-bis[4-(2-hydroxy-3-methacryloyloxypropyloxy)phenyl] propane (Bis-GMA). e second group was categorized as poly-urethanes. The polyurethanes are halophosphorus esters of hydroxyethyl methacrylate (HEMA). Both of these dentin-bonding agents relied on a phosphate-calcium bond for retention.Removal of the smear layer was found to increase the eectiveness of the dentin-bonding agents. e newer bonding agents include conditioning or primer components that remove or alter the smear layer over the dentin. is results in the creation of a mechanical bond by the inltration of monomers into a zone of demineralized dentin, where the monomers polymerize and interlock with the dentin matrix.17 A majority of the contemporary dentin-bonding agents are similar to those previously discussed or are composed of 4-methacryloxyethyl trimellitic anhydride.ionization attack the calcium aluminosilicate glass, which also contains uoride, and causes the release of metal and uoride ions. e majority of the metal cations (Ca2+, Al3+), divalent or trivalent, respectively, are bound by the ionized polymer to form cross-linked salt bridges. Calcium and aluminum ions bind to polyacrylic acid at the carboxyl groups, and a gel phase is precipitated to form a matrix of the hardening cement. Calcium carboxylates are formed rst as a rm gel because of the rapid binding of calcium to the polyacrylic acid chains. is initial set has the property of being carvable, but at this stage the ionomer is very susceptible to water absorption. Likewise, the free aluminum ions are susceptible to diusion from moisture contamination and thus are lost from the cement because they are unable to cross-link with the polyacrylic acid chains. Isolation of prepared teeth is recommended. Aluminum salt bridges are then formed with the polyacrylic acid matrix, and the cement hardens. e trivalent aluminum ions ensure a much stronger cross-linking than is possible with the calcium divalent bonds alone. e slower reaction of aluminum ions is attributed to the more stringent steric requirements imposed by a trivalent ion on a polyanion chain conguration.Glass ionomer can bond to dentin by free hydrophilic carboxyl groups in the cement, promoting surface wetting to form hydrogen bonds at the tooth interface. At the same time, an ionic exchange occurs at the interface, with calcium ions being displaced by • Figure 21.2 Zinc oxide–eugenol cement (Cavitec). (Courtesy Kerr Cor-poration, Orange, CA.)• Figure 21.3 Glass ionomer cement (GC Fuji Lining LC). (Courtesy GC America, Alsip, IL.) 296 Part 3 The Primary Dentition Years: Three to Six Yearsaddition of copper require less mercury than comminuted particles to complete the amalgamation process. It is important to point out that once amalgamation occurs, unreacted mercury is not available; the mercury is alloyed with silver, tin, or copper. Zinc is present in some alloy mixes to act as a scavenger for oxygen, which inhibits the formation of copper, silver, or tin oxides, thus weakening the amalgam restoration. Using preencapsulated amalgam (Fig. 21.5) and strictly following the manufacturer’s recommenda-tions for trituration and manipulation are critical in achieving restoration success.PropertiesHardening amalgam may expand or contract depending on the type and manipulation of the material. e American Dental Association23 requires that there be no more than 20 µm/cm of expansion or contraction after 24 hours.e compressive strength required by the Council on Dental Materials and Devices23 for amalgam is 11,600 psi (88 MN/m2) after 1 hour. Tensile strength is substantially lower; therefore cavity preparation design becomes critical. e preparation should have a design that allows the amalgam to be condensed as a “bulk” of material, avoiding shallow depths and a thin isthmus where fracture may occur. Comminuted and spherical low-copper amalgam demonstrates decreased marginal fracture resistance. is is partially due to the increased creep of these amalgams. Creep is the dimen-sional change that occurs when amalgam sustains a load during mastication, a result of the viscoelastic property of amalgam. e American Dental Association requires that an amalgam have a maximum of 5% creep to be certied.Corrosion, a chemical or electrochemical deterioration of amalgam, occurs at the surface or subsurface. Deterioration may be due to pitting or scratching secondary to poor condensation, carving, or nishing of amalgam, which allows food or saliva components to attack the chemical matrix. Dissimilar metals in contact with each other can also cause corrosion as a result of a galvanic action that encourages the materials to go into solution. is leads to pitting and food entrapment within the pits, which subsequently causes further corrosion. The gamma 2 phase Self-etching bonding systems (Fig. 21.4) have been developed to oer the convenience of etching and bonding simultaneously. Although research demonstrates adequate bonds to dentin and enamel, caution is advised. e products must be used as instructed by the manufacturer, particularly focusing on agitation of the product during placement and the recommended length of applica-tion time.18,19Restorative MaterialsAmalgamTraditionally, amalgam was the material of choice for class I and class II restorations. Today amalgam continues to be an eective restorative material.20,21 A 3-year study of the clinical performance of 260 amalgam restorations (86.4% class II) demonstrated 254 to be successful.22 It is important to understand the clinical makeup and setting reaction of amalgam to correlate restoration successes and failures with the fundamental properties of the material.AmalgamationDental amalgam consists of an alloy mix of silver, copper, tin, and, in some cases, zinc particles combined with mercury. e alloy particles have either a spherical or comminuted (lathe-cut) congura-tion. e unreacted alloy particles are termed the silver-tin (gamma) phase. ese particles are combined with mercury, the mercury actually acting as a wetting agent of the alloy particles to initiate the setting reaction termed amalgamation. e particle surfaces react with mercury to form a cementing matrix, consisting of the gamma 1 and gamma 2 phases. e gamma 1 phase employs the binding of silver and mercury (Ag2-Hg3). e gamma 2 phase involves the binding of tin and mercury (Sn7-Hg). e gamma 2 phase is responsible for early fracture and failure of the comminuted particle amalgam restorations. Tin cannot be eliminated from the alloy because of its importance in the setting reaction and control of dimensional change of amalgam. To avoid the detrimental gamma 2 phase, copper was introduced into the amalgamation reaction. e copper replaced the tin-mercury phase with a copper-tin phase (Cu5-Sn5). e copper-tin matrix decreases the corrosion of tin, preventing secondary weakening with subsequent fracture of the restoration.e amount of mercury needed to complete the amalgamation reaction is contingent on the alloy composition and particle conguration but usually falls between 42% and 54% of the amalgam mix. When mercury exceeds 55%, there is a detrimental reduction in amalgam strength. Spherical alloy particles with the • Figure 21.4 Self-etching bonding system (OptiBond All-In-One). (Cour-tesy Kerr Corporation, Orange, CA.)• Figure 21.5 Preencapsulated amalgam (GS-80). (Courtesy SDI [North America], Bensenville, IL.) CHAPTER 21 Dental Materials 297 in cavity preparation, and advances in the stability of compositional properties of the material.Conventional resin-based composites were viscous uid non-volatile monomers (Bis-GMA) that have ller particles incorporated into the resin. Bowen26 formulated the Bis-GMA resin by synthesiz-ing a dimethacrylate monomer, the product of the reaction between bisphenol A and glycidyl methacrylate. Many contemporary composite restorative materials contain dimethacrylate monomers (Bis-GMA) as the major component of the matrix phase. A relatively low-viscosity monomer (triethylene glycol dimethacrylate [TEGDMA]), which helps produce the desired handling qualities of the material, is an important component of the matrix phase. Fig. 21.7 schematically illustrates the chemical structure of Bis-GMA, and Fig. 21.8 illustrates the chemical structure of TEGDMA.Incorporated into the monomer matrix are ller particles. A small number of available products contain urethane dimethacrylates rather than the Bis-GMA matrix. Initially, fused quartz and various glasses were incorporated into the Bis-GMA monomer as ller particles, providing a reinforced resin composite. e llers were coated with a vinyl silane coupling agent, with the silane chemically bonding with the polymer matrix.27 ese particles were usually irregularly shaped to provide mechanical retention in the resin.Composites available today contain quartz, colloidal silica, borosilicate glasses, and glasses containing barium, strontium, and zinc. Excluding quartz and colloidal silica, these ller particles give the material radiopacity, which is clinically advantageous during radiographic examination. Contemporary posterior resin-based composites contain a high percentage by volume of ller particles. is composition provides wear resistance and more stability.28 (tin-mercury) is most susceptible to corrosion; therefore the spherical high-copper amalgams are the least susceptible. Although extensive corrosion can lead to restoration failure, minimal corrosion in conjunction with creep allows open restoration margins to be packed full enough with corrosion by-products to signicantly close these margins.CondensationAmalgam should be placed and condensed immediately after trituration, according to the manufacturer’s recommendations. Placement of amalgam in small increments is appropriate. Condensa-tion allows force to be applied for material adaptation with a minimum of excess mercury. Use of small condensers with rm pressure on small increments of amalgam minimizes voids within the nal restoration. A delay in condensation should be avoided because the initial hardening that occurs after trituration but before condensation may make the eective removal of excessive mercury more dicult. is, in turn, decreases restoration’s strength and increases the creep in the material. Moisture contamination should also be controlled because excess moisture causes delayed expansion, particularly in zinc-containing alloys. e use of isolation devices can prevent moisture contamination and isolate the working eld eectively.Finishing and PolishingFinishing and polishing of the amalgam surface are highly recom-mended. Small scratches and pits can be removed with nishing burs, and abrasive stones and rubber points can be impregnated with abrasives. e nal polish can be accomplished with a tin oxide compound. Care should be taken to use water when polishing to prevent the vaporization of mercury from the amalgam. Most amalgam restorations should not be polished for 24 hours, although the spherical high-copper amalgam can be polished almost imme-diately because its strength is obtained rapidly.Resin-Based CompositeResin-based composite (Fig. 21.6) has become one of the most widely used contemporary restorative materials over the past 30 years. Currently resin composite is used for sealants and for class I through V restorations in primary and permanent teeth.24,25 Resin-based composite restorations have been accepted primarily because of their excellent esthetic qualities. Other advantages include relatively low thermal conductivity, preservation of tooth structure • Figure 21.6 Resin-based composite system (Herculite Ultra). (Courtesy Kerr Corporation, Orange, CA.)• Figure 21.7 Chemical composition of 2,2-bis[4-(2-hydroxy-3-methacryloyloxypropyloxy)phenyl] propane (Bis-GMA). • Figure 21.8 Chemical composition of triethylene glycol dimethacrylate (TEGDMA). 298 Part 3 The Primary Dentition Years: Three to Six Years(camphorquinone) and an amine catalyst (dimethylaminoethyl methacrylate). e diketone absorbs light at approximately 470 nm to form an excited state, which, together with the amine, results in ion radicals to initiate free radical polymerization.37,38In attempts to reduce polymerization shrinkage, resin molecules longer than Bis-GMA have been placed in resin-based composites. An example would be EMA-6, which can be found in Filtek Z250 (Fig. 21.9; 3M ESPE Dental Products, St. Paul, MN).39Problems that may be associated with light-activated resin-based composites include polymerization toward the light source, sensitivity of composite to ambient light, and variability in the ermal expansion and polymerization contraction are both reduced by increasing the volume percentage of ller particles. e increased ller content, needed for wear resistance, requires a decrease in matrix resin polymer, therefore allowing for a reduction in the amount of shrinkage that occurs upon polymerization. As the concentration of ller particles increases, the modulus of elasticity increases and tends to minimize shrinkage.29Resin-based composites absorb water, yet hygroscopic expansion is very infrequently sucient to compensate for polymerization shrinkage.30,31 erefore the incremental placement and poly-merization of resin-based composite are critical during restorative care.32–35Chemically Polymerized Resin-Based Compositee traditional chemically activated resin-based composites form cross-links during copolymerization of methyl methacrylate and ethylene glycol dimethacrylate. e dimethacrylate monomers polymerize by means of free radical–initiated polymerization to form the organic matrix of a three-dimensional network. is highly viscous monomer can undergo free radical addition poly-merization to provide a rigid cross-linked polymer. Usually the benzoyl peroxide present in one paste acts as the initiator, whereas a tertiary amine (dihydroxyethyl-p-toluidine) acts as the catalyst in the other paste.36Visible Light–Polymerized Resin-Based CompositeToday most resin-based composites are visible light–activated materials (see Fig. 21.6). is allows for more controlled, incremental placement of material into a cavity preparation. The visible light–activated composites usually contain a diketone initiator • Figure 21.9 Resin-based composite with EMA-6 (Filtek Z250). (Cour-tesy 3M ESPE Dental Products, St Paul, MN.)DENTAL LIGHT-CURING UNITSSharukh S. Khajotia and Fernando L. Esteban FlorezDental light-curing units are handheld devices that are used for the polymerization of visible light–activated dental materials. The four types of light-curing units that are currently available include quartz-tungsten-halogen (QTH), light-emitting diode (LED), plasma arc curing (PAC), and Argon laser units.QTH light-curing units are the most widely used and are made of a quartz bulb containing a tungsten lament in a halogen environment. QTH units emit ultraviolet irradiation and visible light (broad-spectrum), which is ltered to limit the wavelength output to between 400 and 500 nm while also minimizing heat. The intensity of light emitted by a QTH bulb ranges from 400 to 1200 mW/cm2 and can decrease with use. The use of a radiometer is recommended for the routine monitoring of the light intensity, and permitting the built-in fan to cool the QTH bulb is recommended to facilitate optimal function of the unit.LED light-curing units emit light in the blue part of the visible spectrum, typically between 440 and 490 nm, and do not emit heat. Therefore LED units do not require lters. They can be powered by rechargeable batteries because they require low wattage, and they are quieter than QTH units because they do not need a cooling fan. Initial versions of LED units emitted a lower intensity of light, whereas newer versions incorporate multiple LEDs with a variety of ranges of wavelengths to broaden the spectrum of the emitted light and increase the overall intensity in order to adequately polymerize all visible-light activated dental materials.PAC light-curing units contain a xenon gas that is ionized to produce plasma. The high-intensity white light emitted is ltered to minimize heat and to limit the output to the violet-blue part of the visible spectrum (400–500 nm). Argon laser units emit the highest intensity and emit light at a single wavelength (approximately 490 nm). The higher costs associated with the use and maintenance of the PAC and Argon laser units has limited their widespread use in dentistry.Visible light-activated dental materials contain an initiator such as camphorquinone (CQ) that absorbs light at the appropriate wavelength (approximately 470 nm for CQ). The free radicals necessary for the initiation of polymerization are generated when the initiator combines with an organic amine such as dimethylaminoethyl methacrylate (DMAEMA). The wavelength, intensity, and duration of exposure to light determine the number of photons absorbed by the initiator and therefore impact optimal polymerization. Factors such as light-curing unit intensity, angle of illumination, diameter of the tip of the light source, distance from the light source, and duration of exposure can signicantly affect the number of free radicals formed, thereby making this system highly technique sensitive. Initiators other than CQ are also used in visible light-activated materials. Because they absorb light at different wavelengths than CQ, it is critical that the light-curing unit used emits light at the requisite wavelength for that particular initiator.Newer light-curing units have higher intensities, typically greater than 1000 mW/cm2, which permit either shorter durations of cure for a given depth of cure or increased depth of cure for a given duration of cure. The use of these higher intensity lights can, however, produce higher shrinkage stresses within the restoration. It is important to remember that the type of light-curing unit and curing mode used impact the polymerization kinetics, polymerization shrinkage, and associated stresses, microhardness, depth of cure, degree of conversion, color change, and microleakage in visible-light activated restorations. Lastly, precautions such as protective eyewear and light shields are critical for the safety of the patient and clinic personnel when using dental light-curing units. CHAPTER 21 Dental Materials 299 adequate hardness, are distributed within minimal unlled resin, and have the least abrasion potential during mastication.28,56 Thus, more recently, nanoparticles have been introduced as ller particles.Porosity has been shown to be a major factor in the wear rate of posterior resin-based composites.55,57 All resin restorations contain a certain degree of porosity and voids. ese defects can be minimized by careful placement technique and polishing of the material. Because light-cured composites do not require mixing, they contain fewer voids. Problems of wear appear to be improved with newer composites. Composite resins are vacuum-packed to decrease porosity. It is important to note that mixing shades for esthetics may increase the porosity. is problem is created from the incorporation of air during the mixing process. Current posterior resin-based composites show minimal wear. is has been achieved by incorporating a variety of particle sizes into the polymer matrix. e increased ller content decreases the amount of matrix resin polymer. e mechanism of wear is hypothesized to be due to the loss of the resin matrix. Increasing wear resistance is believed to be possible because the ller particles are closely packed, thereby leaving little unlled resin exposed.Marginal Adaptatione use of resin-based composites for restoring posterior teeth has historically presented the problem of marginal leakage at the resin-tooth interface.54,58 is marginal leakage caused teeth with posterior resin-based composite restorations to be more prone to secondary caries than teeth with amalgam restorations. Failure of the composite to bond to the cavity preparation walls and voids in the restorative material have been identied as the causes of inadequate marginal adaptation. is problem has been reduced by (1) using contemporary posterior resin-based composites, which contain a high volume of ller that decreases polymerization shrinkage; (2) using an enamel bevel; (3) using newer dentin-bonding agents and glass ionomer cements; and (4) acid etching the enamel.FormulationsEnamel-Bonding Agentse use of phosphoric acid (35% to 50%) results in an acid-etched surface on enamel that creates an eective mechanical bond with the Bis-GMA enamel-bonding agent. Enamel-bonding agents (Fig. 21.10) are placed over the acid-etched enamel before composite placement. e bonding agents are merely unlled dimethacrylates and are used because their low viscosity allows easy penetration of the etched enamel surface. e resin matrix of the resin-based composite will then chemically bond to the bonding agent.Sealantse use of pit and ssure sealants has been eective in preventing occlusal caries for almost ve decades.59–61 Traditional sealants are hydrophobic and are composed of a Bis-GMA resin structure used in resin-based composites. e Bis-GMA monomer is diluted with low-weight dimethacrylate monomer to make the sealant material a uid that can easily penetrate the pits and ssures of occlusal surfaces. A new generation of resin-based sealants is formulated with hydrophilic resins that behave favorably in the moist environment (Fig. 21.11). ese materials contain no Bis-GMA or bisphenol A derivatives, have better adaptation to tooth structure, and provide a better seal.Although the use of sealants is an excellent preventive technique, initially there were concerns that caries could occur at sealant depth of polymerization due to the intensity of light penetration. Polymerization toward the light source may cause the resin-based composite to pull away from the walls of the preparation. Sensitiv-ity of resin-based composite to ambient light may cause initial polymerization before placement of the material into the prepara-tion. Variability in the depth of light penetration, dierences in curing light intensity, diameter of the tip of the light source, and time of light exposure can result in variations of polymerization. e benets of light-activated resin composites include ease of manipulation, control of polymerization, and lack of need for mixing. Since mixing is not required with light-activated composites, it is less likely that air will be incorporated and form voids in the mixture.Bulk-Fill ResinsExtensive eorts have been made over the last decade to develop low shrinkage resin-based composites through advances in ller technology and monomer chemistry.40,41Conventionally the maximum incremental thickness of resin-based composite that provided adequate light penetration and polymerization was defined as 2 mm.42,43 Use of these conventional materials requires a layering technique that is time consuming and has the potential to introduce voids, thus increasing the risk of failure.44 e risk of failure presents itself clinically by allowing the ingress of bacteria, ultimately leading to secondary caries, pulpal inammation, necrosis, or postoperative sensitivity.Recently a new class of resin composite materials, the bulk-ll resin composites, has been introduced. Clinical recommendations suggest that these materials have a greater depth of cure, which allows them to be placed in 4-mm bulk increments and still have adequate polymerization.is innovative technology is based on changes in monomer chemistry by modifying the Bowen monomer (Bis-GMA: 2,2 bis [4-(2-hydroxy-3-methacryloxypropoxy) phenyl] propane) to create monomers with lower viscosity.45–48 is new modication is achieved by incorporating hydroxyl-free Bis-GMA aliphatic urethane dimethacrylate or highly branched methacrylates.49 e outcomes of these changes in monomer and composite organic matrix have been shown to reduce polymerization shrinkage stresses over 70%.45,46,50Resin-Based Composite WearEarly resin-based composites, used for posterior restorations, exhibited excessive occlusal wear. Studies have shown that when conventional composites are placed in high stress concentration areas, excessive wear occurs.51–54 Further investigations pursued factors that might inuence the rate of wear, such as the size and hardness of the ller particles, the amount of porosity within the material, and the method of polymerization.55 It was found that the ceramic ller particles nearly always remained intact. ere was no evidence of wear on the particles themselves; they were found to be hard enough to cause wear of the surrounding unlled resin during mastication until the resin matrix gradually wore away from the particles. Once a critical portion of the ller particle was exposed, it was easily dislodged. Although there seemed to be a correlation between the size of the ller particle and its hardness (larger particles possessing a more critical hardness), substantially larger particles were found to accelerate the wear. erefore the hardness of particles is not necessarily the most signicant factor aecting wear. e ideal material would have particles that have 300 Part 3 The Primary Dentition Years: Three to Six YearsABCD• Figure 21.12 (A) Microll material. (B) Macroll material. (C) Hybrid material. (D) Nanoll material. (From Freedman G. Contemporary Esthetic Dentistry. St Louis: Mosby; 2012.)• Figure 21.11 Pit and ssure sealant (EMRACE WetBond). (Courtesy Pulpdent Corporation, Watertown, MA.)• Figure 21.10 Enamel bonding agent (E-Bond). (Courtesy Danville Materials, San Ramon, CA.)margins or where the sealant had partially broken away. e concept of adding uoride-releasing resins was examined for caries inhibition and found to be eective in vitro.62,63 Most sealants currently in use contain uoride and are light-cured. Two component systems that self-polymerize are also available.Microlled Resin–Based CompositeMicrolled resin–based composite (Fig. 21.12A) has silane-treated colloidal silica ller particles in a Bis-GMA resin. Traditional microlled composites contained approximately 50% (by volume) ller particles. Because of the high percentage of resin matrix, the particle conguration, and the small particle size (< 1 µm in diameter), this resin composite is easily polished and reaches a high luster. Microlled composites are recommended for restorations that are highly visible yet encounter minimal stress during mastica-tion. e low percentage of ller results in a decrease in strength

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