HERE - The Dental Specialists

What I will cover
IS THIS GOING TO HURT?
Brief overview of orofacial pain
Recent findings on post-treatment pain
Tips for managing pain during treatment
Tips for managing pain after treatment
Alan S. Law, DDS, PhD
Endodontist, The Dental Specialists, Twin Cities, MN
Adjunct Associate Professor, Division of Endodontics, University of Minnesota
May 14, 2015
1
A Brief Review of the Trigeminal
Pain System
2
The Steps in Pain Perception
• Detection
• Processing
• Perception
3
4
Detection
Detection
1. Most pulpal sensory fibers are
nociceptive
2. Terminal branches= free nerve
endings
3. Stimulation- PAIN
4. Difficult to localize
Repeated noxious stimulation
•
•
•
5
Decrease firing
thresholds= Allodynia
After discharges
producing greater
perceived pain intensity=
Hyperalgesia
Spontaneous firing=
Spontaneous pain
6
Processing
1. In the medullary dorsal
horn
2. Relays information to
higher centers of the brain
•
•
•
Intensity
Quality
Temporal features
3. Output can be increased,
decreased or
misinterpreted
Perception
1. Patients perceive a
stimulus as painful at the
cortex level
• A disproportionately large portion of the sensory cortex in humans is devoted to input from orofacial regions
2. Cortical perceptual
processes have a
profound effect on the
ultimate state of pain the
patient experiences
7
8
“Trust, but verify.”
Tips for
managing
pain
during
treatment
A positive “lip sign”
does not guarantee
pulpal anesthesia. A
more reliable indicator
is to retest the tooth
with cold (Endo-Ice®)
9
10
A caution, if patients have
already taken ibuprofen
PDL Injection
Preoperative
administration of
nonsteroidal antiinflammatory drugs
(e.g., ibuprofen) may
increase the
effectiveness of the
local anesthetic IAN
block
• Length or gauge of needle not important
• Onset of anesthesia is generally more rapid
than nerve block or infiltration
• Is effective 92% of time in patients who
experienced inadequate pulpal anesthesia
Walton RE, Abbot BJ. Periodontal ligament injection: a clinical evaluation. J Am Dent Assoc
1981;103:571–5.
Winter 2009, Colleagues for Excellence www.aae.org/colleagues
11
12
PDL Injection
Inject on mesial and distal
Intraosseous Injection
Intraosseous
administration of a local
anesthetic significantly
enhances the efficacy of
an IAN nerve block
injection
*acute tachycardia may
occur when using epi,
which precludes its use in
some patients
13
14
Buccal Infiltration with Articaine
Can use of analgesics prior to
an appointment “mask”
Administration of a 4%
articaine solution into the
buccal vestibule of the
mandible also enhances the
efficacy of an IAN block
injection
Matthews et al. Articaine for supplemental buccal mandibular infiltration anesthesia
in patients with irreversible pulpitis when the inferior alveolar nerve block fails. J Endod, 2009:35(3)343–6.
15
In teeth with diagnosis of symptomatic irreversible
pulpitis and symptomatic apical periodontitis, 800
mg ibuprofen reduced:
•
•
•
palpation pain by 40%
percussion pain by 25%
cold pain by 25%
* Ask which analgesics were taken 4-6 hours prior
to evaluation
Read JK, McClanahan SB, Khan AA, Lunos S, Bowles WR. Effect of
Ibuprofen on masking endodontic diagnosis. J Endod. 2014;40(8):1058-62.
16
Study Timeline
Pain in first week posttreatment
17
18
Root canal therapy reduces
multiple dimensions of pain
Mean change from preoperative week to
postoperative week*
• Worst pain intensity
• Average pain intensity
• Days experienced tooth pain
3.4
• Interference with daily activities
2.9
-2.3 ± 4.4
-2.3 ± 3.5
-1.5±
Law
al. Root canalin
therapy
reduces multiple
dimensions
A National
* allet changes
dimensions
of pain
wereof pain:
statistically
Dental Practice-based Research Network study. J Endod 2014;40:1738–1745.
-0.9 ±
significant
Law et al. Root canal therapy reduces multiple dimensions of pain: A National
Dental Practice-based Research Network study. J Endod 2014;40:1738–1745.
19
20
Predicting Severe Pain after
Root Canal Therapy
652/708 patients completed questionnaires
19.5% (n = 127) reported severe pain
Baseline factors predicting severe postoperative pain
•
•
current pain intensity (odds ratio [OR] = 1.15; p = 0.0003)
number of days in past week pt kept from usual
activities due to pain (OR, 1.32; p = .0005)
•
pain made worse by stress (OR, 2.55; p = 0.0130)
diagnosis of symptomatic apical periodontitis (OR,
•
1.63; p = 0.0452)
Law et al. Root canal therapy reduces multiple dimensions of pain: A National
Dental Practice-based Research Network study. J Endod 2014;40:1738–1745.
21
Predicting Severe Pain after
Root Canal Therapy
Factors that did not contribute to
predicting severe postoperative pain
•
•
•
•
•
dentist’s specialty training
patient’s age and sex
type of tooth
presence of swelling
other pulpal and apical endodontic diagnoses
Law et at. Predicting severe pain after root canal therapy in the National Dental
PBRN. J Dent Res 2015;94(3)37-43.
22
Tips for
managing
pain
during
treatment
Law et at. Predicting severe pain after root canal therapy in the National Dental
PBRN. J Dent Res 2015;94(3)37-43.
23
24
Comparative Efficacy of Oral
Analgesics (Moderate to Severe
% Patients with
Analgesic
50% Pain Relief **
Ibuprofen 800 mg
100%
Ibuprofen 600 mg
79%
Acetaminophen 650 mg + Oxycodone 10 mg
66%
Acetaminophen 1,000 mg + Codeine 60 mg
57%
197
Ibuprofen 400 mg
56%
Morphine 10 mg IM injection
50%
Acetaminophen 1,000 mg
46%
Ibuprofen 200 mg
45%
Acetaminophen 600/650 mg
38%
Tramadol 100 mg
30%
Codeine 60 mg
15%
Placebo
18%
Sample Size (N)
76
203
315
4,703
946
2,759
1,414
1,886
882
1,305
>10,000
1.
2.
Hargreaves, K. Endodontic Colleagues for Excellence, Winter 2015
Data from: The Oxford League Table of Analgesic Efficacy
** Percentage of patients with moderate to severe pain who report at least 50 percent pain
relief at four hours to six hours after taking medication.
Data are from randomized, double-blind, placebo-controlled analgesic clinical trials.
25
26
Tips for managing post-treatment
Tips for managing post-treatment
Simultaneous administration
of ibuprofen and APAP
produces greater peak
analgesia and more
consistent analgesia without
increasing adverse side
effects
McQuay et al. Evidence for analgesic effect in acute pain - 50 years on. Pain. 2012;153(7):1364-7.
Menhinick et al. The efficacy of pain control following nonsurgical root canal treatment using ibuprofen
or a combination of ibuprofen and acetaminophen in a randomized, double-blind, placebo-controlled
study. Int Endod J. 2004;37(8):531-41.
Mehlisch et al. A single-tablet fixed-dose combination of racemic ibuprofen/paracetamol in the
management of moderate to severe postoperative dental pain in adult and adolescent patients: a
multicenter, two-stage, randomized, double-blind, parallelgroup, placebo-controlled, factorial study. Clinical therapeutics. 2010;32(6):1033-49.
27
Thank you!
Antibiotics should
not be used solely
for management of
pain
• Use only for fever,
swelling, malaise or
compromised
airway
Baumgartner C. Endodontics Colleagues for Excellence, Summer, 2006
28
SHOULD I BE WORRIED ABOUT THIS THING IN MY MOUTH?
Todd C. Gerlach, DDS
Diplomate, American Board of Oral and Maxillofacial Surgery
May 14, 2015
29
30
Worried or Not??
31
32
History
Examination
• Chief complaint
• History of present illness
• Past medical history
• Past dental history
• Visual
• Palpation
• Radiographic
33
34
What is abnormal?
What is there?
• Color changes
• Ulcerative lesions
• Growths
• Soft tissue masses
• Swelling
35
• Mucosa
• Connective tissue
• Vessels
• Nerves
• Muscle
• Salivary glands
36
Red Flag
• Numbness
• Loss of function
• Solitary periodontal lesion
• Pain - very late
• Dark - brown/black
• Rule out melanoma
• Systemic disease
• Blue or purple
• Rule out salivary gland tumors
• Vascular lesion
37
38
Color Changes
Color Changes
• White
• Many, many lesions
• Rule out dysplastic changes - leukoplakia
• Red
• Inflammation
• Erythroplakia
•
Color Change
39
40
Color Changes
Color Changes
• Malignant transformation
• Women
• Long duration of leukoplakia
• Non-smokers
• Tongue and floor of mouth location
• Non-homogeneous type
• Presence of epithelial dysplasia
White
• Tongue and
floor of mouth
increase
suspicion of
dysplasia
41
42
Ulcerative Lesions
• Most common traumatic
• Short-term often systemic
• Herpes, aphthous, hand-foot-mouth
• Long-term
• Rule out dysplastic changes
• Pemphigus - pemphigoid (ocular too)
• Often papillary like
• Papilloma, proliferative verrucous
leukoplakia
43
44
Soft Tissue Masses
Soft Tissue Masses
• Lip
• Upper > lower for malignancy
• Mucosa - buccal and alveolar
• Mostly benign
• Extension of large tumor
• Bony hard - need radiograph
•
Growths
• Floor of mouth
• Salivary or cystic
• Tongue
• Malignant generally with large lesion
• Benign tumors
• Elongated taste buds
45
46
Soft Tissue Masses
Swelling
• Infection
• Bony hard
• bone pathology
Palate
• Salivary tumor
• Lymphoma
47
48
Questions?
WHEN SHOULD I BE REFERRED TO A PERIODONTIST?
Tom Hoover, DDS
TDS Perio (Lake Elmo, Fridley and Maple Grove)
May 14, 2015
49
50
Periodontitis
The Data
-
National Health and Nutrition Examination
Survey (NHANES) 2009-2010
First time that NHANES used full mouth probing
-
-
-
51
52
The Data cont.
Patient awareness
- NHANES data only included periodontitis,
gingivitis was excluded
- There is plenty of periodontal disease to be
treated, and the disease is a chronic condition
(patients are always susceptible to it)
-
Requires an integrated team approach
-
Previous NHANES underestimated prevalence
In adults 65 and over, 70.1%
Higher prevalence in men
Highest prevalence in Mexican-Americans
Smoking, poverty and education also factors
General Dentists, Hygienists and Periodontists
- So, when should it be referred?
53
- There is a surge in awareness about periodontal
disease
-
Desire to retain the natural dentition
Advances in periodontal therapies
Additional training in dental schools
Threat of legal action for non or misdiagnosis
A large number of consumer devices are available for
assisting with home care measures
54
Goals of periodontal therapy
- Create a situation where the disease can be
managed over the long term
-
Reduction of probing pocket depths (3mm or less)
Correction of mucogingival defects
Favorable environment for home care practices
Change in patient behavior and attitude towards
periodontal disease
How successful are we?
Maintenance
Teeth Lost (no.)
Population (%)
0-3
83.6%
2.6%
Downhill
4-9
12.6%
22.7%
10-23
4.2%
55.4%
Extreme downhill
- Hirschfeld and Wasserman 1978. Studied 600 patients over 22 years in which 39%
received surgical care. They found an overall tooth loss rate of 7.1% (0.08 teeth per
patient per year) and 31% of the teeth that were lost had furcations.
55
56
How successful are we?
When to refer?
Maintenance
Teeth Lost (number)
Well-maintained
77%
4-9
15%
10-23
3%
Downhill
Extreme Downhill
Population (%)
0-3
- McFall (1982) studied 100 patients over 19 years in which 63% received surgical
care. He found that 9.8% of all surgically treated teeth were lost and 7.1% of nonsurgically treated teeth were lost. 56.9% of teeth with furcations were lost.
Teeth Lost (%)
Well-Maintained
- When you don’t want to treat the condition in
your practice
- When there isn’t time to treat the case in your
practice
- When the case is too difficult
-
Both in presentation of the disease or the patient
themselves
- When treatment is not providing satisfactory
results
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Treatable conditions in General Practice
Referral cases
- Gingivitis
- No loss of attachment and probing of < 4mm.
- Moderate periodontitis
- Probing of 4-6mm, treated initially with SRP
- Re-evaluation is essential (usually 6 weeks) to
determine the need for further treatment (i.e. surgery)
- Periodontal maintenance (alternating)
59
- Systemic illness that requires treatment
modification
-
Diabetes
Cardiovascular diseases
Pulmonary diseases
Immune compromise
Transplant and chemotherapy patients
Chronic hepatitis patients
60
Referral cases cont.
Referral cases cont.
- Osseous defects
- Early, severe disease
- These will typically not resolve themselves with non-surgical treatment
- Children, teenagers and young adults with aggressive
periodontitis
- Extraction decisions and prosthodontic
considerations
- “Is this tooth worth restoring?”
- Severe periodontitis, particularly of the anterior
teeth
-
Biologic width issues
Recession defects and loss of attached gingiva
Dental implants
Any persistent pockets that don’t resolve with non-surgical therapy
61
62
Barriers to referral
Barrier to referral
- From clinicians
- Patient barriers
- Financial constraints
- Fear of pain
- Inconvenience/time issues
- Once referred, the patient never returns
- There are no periodontists within easy driving distance
- Lack of documentation/communication between the
specialist and the referrer
- Fear that existing dental work might be critiqued
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Items included in a referral
Items included in a referral
- Areas to be evaluated (generalized vs. localized)
- Any restorative plans (particularly crowns)
- Current radiographs
- If the referral is for a single tooth, PA in addition to
BWX
- BWX not need for anterior recession cases
- FMX preferred, pano can be useful
65
- History of periodontal treatment (SRP, surgery,
maintenance, maintenance interval)
- Name of the referring Doctor (especially in group
practices!)
- Not necessary, but I do occasionally receive formal
letters from referrals
66
Items you should receive in return
- A report including diagnosis, prognosis and
recommended tx plan, perio maintenance plan
- Did the patient accept the treatment?
-
A copy of periodontal charting
Copies of any radiographs taken by specialist
Answers to the questions asked in your referral
Referrals should not complicate your daily
practice, but rather enhance it
Closing thoughts
- Not all perio needs the attention of a specialist
- It must, however, be closely monitored in general
practice, the same that it would be at the specialty
levels
- Re-evaluation of non-surgical therapy and periodontal
maintenance
- If a case is progressing downhill, refer it sooner
than later
- Easier to manage if the damage is minimal to moderate
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Closing thoughts
Closing thoughts
- Emphasize with your pts. that perio disease is not
going to go away and that they are always
susceptible
- Present the concept of perio maintenance at the time of
diagnosis
- If pts. choose not to pursue periodontal treatment,
keep emphasizing it to them and document their
rejection of your treatment suggestions!
DOCUMENT!
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- Well controlled periodontal disease leads to better
restorative dentistry and more enjoyable
restorative practice
- There are no practices out there that have zero
periodontal disease in them
- If you are not getting what you need from the
specialist, always ask! Communication is key to
long term success in managing perio.
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Questions?
WHEN SHOULD MY CHILD BE REFERRED TO THE ORTHODONTIST?
Benjamin Allen, DMD, MD, MS
The Dental Specialists - Orthodontics
May 14, 2015
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Introduction
▪ AAO recommends first exam
at age 7
▪ Can begin to identify problems
▪
▪
▪
▪
Eruption
Crowding
Occlusion
Need for growth modification
▪ Some problems should be
corrected early
Should vs. Could
▪ Should vs. could
▪ Costs of treatment
▪ Money/time
▪ Patient burnout
▪ Root resorption,
decalcification, caries
▪ What should be treated
early?
73
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What Should be Treated Early
Space Maintenance
1.
2.
3.
4.
5.
6.
7.
8.
Space maintenance
Eruption problems
Crowding
Anterior crossbite
Posterior crossbite
Thumb habit
Growth modification
Appearance issues causing psychosocial difficulty
Missing primary canine
▪ Why
▪ Midline shift
▪ Extract contralateral
tooth
▪ Space maintainer on the
lower
▪ Incisors will retrocline
▪ Not needed on the upper
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Space Maintenance
Space Maintenance
1st primary molar
2nd primary molar
▪ Why
▪ Why
▪ Posteriors will mesialize
▪ Posteriors will mesialize
▪ Band and loop or bilateral
space maintainer
▪ Possibly not necessary if
Class I molar
▪ Band and loop or bilateral
space maintainer
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Eruption Problems
Ectopic eruption of canines
▪ Why
▪ Impaction of canine
▪ Resorption of incisors or
premolars
▪ Periodontal issues
Eruption Problems
Ectopic eruption of canines
▪ Resorption occurring
▪ Advanced imaging
▪ Consider uncovering tooth
to pull it in
▪ Extract primary early
▪ High success rate
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Eruption Problems
Eruption Problems
Ectopic eruption of permanent
first molar
▪ Why
▪ Leads to space loss
▪ Treat
•
•
•
•
•
Watch
Separator
Distilizing appliance
Extract and distal shoe
Accept space loss and manage later
▪ Primary should exfoliate when ¾ of permanent root is formed
▪ Treat
▪
▪
Extract the primary tooth
Space maintenance may be required
Eruption Problems
Bone defect, space loss, ectopic eruption
Extract before space loss or ectopic eruption
▪ No permanent tooth
More complex situation
Extract before large bone defect results
Retain if you can
Maintain space?
▪
Impaction of permanent teeth and ectopic eruption
Eruption Problems
▪ Permanent tooth present
▪
▪
▪
▪
▪
82
▪ Why
▪
▪ Why
81
Ankylosed primary teeth
▪
Over-retained primary teeth
Supernumerary Teeth
▪ Why
▪
Crowding and ectopic
eruption
▪ Treatment
▪
▪
Extract as soon as safely
possible
Some can be allowed to
erupt on their own before
extraction
Depends on the future orthodontic plan
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Crowding
Why
Crowding
Should vs. could
▪
▪
▪
▪
Root resorption
Ectopic eruption
Impacted teeth
Periodontal
problems
▪ Simplify future
treatment
▪
▪
▪
▪
Root resorption
Ectopic eruption
Impacted teeth
Periodontal
problems
▪ Simplify future
treatment
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Crowding
Crowding
Mild crowding
▪ Transitional crowding
▪ Treat
▪ Preserve Leeway space
▪ And/or early extraction of
primary teeth
Moderate crowding
▪ Gaining space vs.
extraction?
▪
▪
▪
2x4 appliance
Transverse expansion
Distilization of molars
87
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Crowding
Crowding
Severe crowding
Moderate crowding
▪ Degree and direction must
be reasonable and
compatible with long-term
orthodontic plan
89
▪ Serial extraction
▪
Extraction of primary and then
permanent teeth
90
Anterior Crossbite
▪ Why
▪
▪
▪
▪ Why
Attrition
Gingival recession
Skeletal Class III?
▪
▪
▪ Crowding?
▪
Posterior Crossbite
Prevent with extraction of primary canines
▪ Generally treated upon
discovery
▪
▪ Skeletal problem?
▪ Treat
▪
▪
▪
▪
RME and U2x4
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Thumb Habit
Thumb Habit
▪ Treat
Dental and skeletal changes
▪ Treat early
▪
Possibly wait to be able to
include other teeth in the
treatment.
▪
Retainer with spring
Upper 2x4
Growth modification?
▪ Why
▪
Mandibular asymmetry
Upper crowding
Spontaneous resolution of
dental changes
Prevent further skeletal
change
▪
▪
Child needs to want to stop
Initial interventions
▪
▪
Explanation, bandage, nail polish,
thumb brace
Appliance therapy
▪
▪
▪
Need cooperation
Effective in 85-90%
Leave in for 6 months
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Growth Modification
Growth Modification
Skeletal Class II
Skeletal Class III
▪ Should vs. could
▪ More efficient and equally
effective to treat during the
adolescent growth phase
▪ Earlier treatment is possible
▪ Dental injury
▪ Psychosocial problems
95
▪ Focus on maxillary
protraction
▪ Begin by 10 to see
skeletal change
96
Psychosocial Problems
Appearance issues
▪
▪
▪
▪
Large spaces
Severely rotated teeth
Proclined upper anteriors
Class II profiles
▪ Should vs. could
97
Thank you!
Conclusion
▪ Exams at age 7
▪ Could vs. should
▪
▪
▪
▪
▪
▪
▪
▪
Space maintenance
Eruption problems
Crowding
Anterior crossbite
Posterior crossbite
Thumb habit
Growth modification
Appearance issues causing psychosocial
difficulty
98
The Use of Pit and Fissure
Sealants To Prevent Decay
Tieg Selberg, DDS
The Dental Specialists
99
100
Overview
Indications
● Indications
● PREVENTION – no lesion present
● Technique
● THERAPEUTIC – for early non-cavitated lesions
● Non-cavitated lesions
● Caries-risk assessment
● Use a form to help show the parent
● Consider what risk factors are most important in your
decision
● All recommendations include an assessment of
● Resin sealant vs GI sealant
caries risk prior to sealant placement
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Caries Risk Assessment
Where are caries found on the adult
teeth of children and adolescents?
103
NHANES 1999 – 2004 report showed
that 90% of carious lesions in 6 -19 year
olds were in the pits and fissures of
posterior permanent teeth
These pits and fissures only make up
13% of the tooth surfaces in the mouth
effective as a prevention strategy
●
●
upper molars
Prevention
● Other methods have conflicting research for effectiveness
●
● Runner Up – buccal of lower molars and lingual of
Evidence-based use
● F and sealants the “only” two methods that are proven
●
● Occlusal Surfaces of 1st and 2nd molars
106
treatment. Fontana et al. Dent Clin N Am. 2009
●
The Caries Champ for young
permanent teeth
105
● Evidence-based caries, risk assessment, and
●
104
CHX
Xylitol
Diet modification strategy
Calcium-based strategies
Oral hygiene instruction
Restorative procedures (not a prevention strategy)
107
● Factors influencing the effectiveness of sealants: a
meta analysis. Llodra at el, Community Dent and Oral
Epidemiology 1993
● Relative risk of 24 studies was pooled to derive
prevented fraction (PF).
● PF was 71.36% (95% CI between 69.69 – 72.94%)
● PF provides a percentage of the outcome variable that
can be prevented through exposure to an intervention
vs no exposure
● 71.36% of carious occlusal lesions could be prevented
if sealants were applied via these findings
108
Prevention
● “Pit and fissure sealants for preventing dental decay
in the permanent teeth of children and adolescents.”
A Cochrane review
● Resin based sealant vs no sealant
● 6 studies included (5 from the late 1970s and one from 2012)
● Children aged 5 – 10
● Odds Ratio was 0.12 (95% CI 0.07 – 0.19) – Having resin
sealants highly associated with not having decay
● For example – if the assumption is made 40% of control
tooth surfaces have decay (400 carious teeth per 1000), then
applying a resin sealant to this population would reduce the
carious tooth percentage to 6.25%
Prevention
● Sealant and fluoride varnish in caries: a randomized
trial. Bravo et al. J of Dental Research 2005
● 120 children aged 6 – 8 YO were followed for a total of
9 years (four years of intervention and then 5 years of
follow up)
●
●
Total teeth = 371
Occlusal caries rate by group at nine years
● Control – 76.7%
● Sealant – 26.6%
● Fluoride varnish – 55.8%
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Prevention
Lets step back in time
● “Resin-based sealants effect: after 1 yr 86% caries
reduction; 58% after 4 years” –Pediatric Dental Handbook, also ADA
Council on Scientific Affairs
● Assumes sealants are reapplied as needed for 4 years
● 1950’s, 60’s and 70’s – 70-% of all molar occulsal
surfaces would be decayed within 10 years of
eruption
● BASICALLY EVERYONE WAS HIGH RISK
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112
Changes over the last few decades in
caries rate
RISK ASSESSMENT IS IMPORTANT
● NHANES 1971 – 1974 – prevalence of DF permanent
1st molars in 10 year olds was 55%
● NHANES 1988 – 1994 – this dropped to 15%
● UNLESS WE STILL LIVE IN THE 70s
● We get the biggest bang for our sealant buck if we
seal those at risk – consider the cost/benefit ratio of
what you are proposing
● 2nd molars over the same time period for 16 year olds
– 68% dropped to 25%
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114
70s
● “HEY MAN, SEAL EM ALL”
PRESENT DAY
● CONSIDER RISK and then recommend sealants
● Prior caries experience
● Inadequate fluoride exposure
● Highly susceptible pit and fissure anatomy
● High plaque load
115
116
Technique
Technique - Clean, clean, clean
● Clean, clean, clean
● Agrawal and Shigli (2012)
● Sealants placed in vivo on 4’s later extracted for ortho
● Different methods for enamel preparation
● Brand
● To bond, or not to bond
●
● Not too much sealant
● Dry-field
1) Round bur preparation 2) air-polishing with sodium bicard and
water slurry 3) air-abrading with alumina particles being sand
blasted 4) pumice slurry 5) dry bristle brush 6)60 second etch time
●
Statistically better results (less microleakage) seen for round bur, air
polishing and air abrasion than:
● Longer etch (60 s), bristle brush, pumice slurry
● Brush only still better results than pumice/cup
● Is it attainable to air-abrade for all sealants?
117
Technique - Type
● Light-cured resin
● Kühnisch, et al.: Meta-analysis
●
Traditional light-cured resin based sealants superior for
retention over (83.8% retention over 5 yrs):
● Glass ionomer cements
● UV-light polymerizing materials
● Compomers
118
GI vs resin-based for partially erupted
molars
● Twenty-four month clinical evaluation of fissure
sealants on partially erupted permanent first molars –
Antonson et al. JADA
● Aim – compare retention, marginal staining and
cariostatic properties of GI vs. resin-based sealants
● Study design – 39 patients between 5-9 YO
● Each patient received one GI sealant and one resin-
based sealant at the same appointment, the sealants
were evaluated for retention, marginal staining and
carious lesions at 3, 6, 12 and 24 months
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120
Results
Technique - Brand
● Complete retention rates at 24 months – 40.7% and
● Suggested that less viscous materials flow into
44.4% for resin-based and GI respectively
● Marginal staining was statistically higher in the resinbased group
● No caries detected in GI teeth, but demineralization
seen in resin-based group if the sealant was
completely lost
● Conclusion – GI may be a better option when salivary
contamination is expected
grooves better than more viscous
● Clinpro is used at Uof MN grad program due to
viscosity and other retentive properties – this product is
also unfilled which means you don’t need to adjust the
occlusion following placement
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122
Technique - To bond, or not to bond
● Feigal, et al.; Randomized, blinded study of 165
children
● Comparisons of:
●
●
●
One-bottle prime/bond
Two-bottle prime and bond
No prime or bond
● 5 year study on newly erupting molars on split-mouth
design
● 617 occlusal sealants
● Split-mouth
● No bond on one side
● Bond on the other side
● Retention analyzed over time
● 12 mo, 24, 36, 48, 60
● Negative hazard factors
● Behavior, saliva, early eruption stage, max v mand,
enamel variations
● 441 buccal/lingual sealants
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Technique - To bond, or not to bond
● Positive hazard ratio (<1)
● One-bottle prime/bond system
● Scotchbond Multipurpose provided no positive effect
and was considered detrimental HR = 2.96
● Primer alone no effect, possible negative effect (not
statistically significant)
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● Dentin bonding system theories
● Improve flow of resin into grooves
● Better retention on contaminated surfaces:
●
Partially erupted molars
● Nogourani, et al. : 35 children evaluated over one year
following sealant placement, split mouth design with sealant
alone one side and bond and sealant other side, DL groove
on max 6’s-better retention with bond
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AAPD Clinical Guidelines (Vol 34/No 6, pp 215)
● “Recommendations:
● 4. A low-viscosity hydrophilic material bonding layer,
as part of or under the actual sealant, is
recommended for long-term retention and
effectiveness.27”
Technique - Light cure
● If prime/bond is applied, when do I light cure?
● After bond and after sealant?
● After sealant only?
● Feigal study mentioned light cure after bond and
sealant placed, not in between bond and sealant
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Sealant Level
Dry Field
● Improving Fissure Sealant Quality: mechanical
● 4-handed technique shows superior results (improved
preparation and filling level Geiger et al, J of Dent
2000
● Study indicates that placing the sealant just to the top
of the fissure is best to prevent microleakage
retention rates) –ADA Council on Scientific Affairs, “Exploring four handed
delivery and retention of resin-based sealants.”
● Isolite / Isodry – allows for much quicker procedure and
single operator
● Higher microleakage was seen with overfilling
technique
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Sealing over non-cavitated caries
Results for sealing cavitated occlusal lesions
● The Effectiveness of Sealants in Managing Caries
● 4 studies evaluated sealing non-cavitated lesions, 1
Lesions – Griffin et al. J of Dental Research
● One barrier to sealant placement is the concern by
some dentist of sealing over a lesion, this barrier may
also effect SBSP utilization
● Meta-analysis aimed at identifying randomized and
non-randomized controlled trials and cohort studies
that provided concurrent comparisons of % lesions
progressing – 6 studies found that met their criteria
● Identified cavitated as visually detectible or the lesion
allowed for explorer penetration
study evaluated cavitated lesions and 1 study
evaluated both cavitated and non-cavitated lesions
Tx Groupings
Median annualized
progression rates
Non-cavitated and
sealed
Non-cavitated and nonsealed
Cavitated and sealed
2.6%
12.6%
19.4%
Cavitated and nonsealed
131
59.3%
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Non-cavitated lesions
Bacteria levels in cavitated lesions
● The effect of dental sealants on bacteria levels in
caries lesions – Oong et al. JADA 2008
● No significant increase in bacteria level under sealants
in cavitated lesions
● Number of viable bacteria reduced by 100 fold and the
number of lesions with any bacteria was reduced by
50%
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Evidence-Based Clinical Recommendations for the use of Pit-and-Fissure Sealants: A Report of the ADA Council on Scientific Affairs
134
More Findings – Sound Pit and Fissures
● What is the effectiveness of sealants in preventing the
development of caries on sound pit and fissure surfaces
● Meta-analysis of 10 studies – one-time placement of
autopolymerized sealants on permanent molars – reduced
caries by 78 % at one year and 59% at four or more years
● Meta-analysis of 5 studies – resin based sealants reduced
caries by 87% at one year and 60% at 48 – 60 months
● Meta-analysis of 13 studies – sealants reduced caries by
33% from two to five years after placement
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More Findings – Non-cavitated lesions
Meta-analysis of six studies revealed sealant
placement on non-cavitated carious lesions resulted in
71% reduction in the number of lesions that progressed
up to 5 years
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AAPD Clinical Guidelines
(Vol 34/No 6, pp 215)
● “Recommendations:
● 1. Sealants should be placed into pits and fissures of teeth
based upon the patient’s caries risk, not the patient’s age or
time lapsed since tooth eruption.
● 2. Sealants should be placed on surfaces judged to be at high
risk or surfaces that already exhibit incipient carious lesions to
inhibit lesion progression. Follow-up care, as with all dental
treatment, is recommended.
● 3. Sealant placement methods should include careful cleaning
of the pits and fissures without removal of any appreciable
enamel. Some circumstances may indicate use of a minimal
enameloplasty technique.
● 4. A low-viscosity hydrophilic material bonding layer, as part of
or under the actual sealant, is recommended for long-term
retention and effectiveness.
138
Sealants, What are those? or Do we really need those?
● Highly supported with clinical evidence
● Not covered by my insurance?
● Feel empowered with sealant placement. Quick and
easy procedure that can really help to prevent decay
and all that goes with it (time, money, pain, etc)
139
References
● Kühnisch, J; Mansmann, U; Heinrich_weltzien, R; Hickel, R. Longevity of materials for
pit and fissure sealing--results from a meta-analysis. Dent Mater. 28 (3) Mar: 298-303,
2012.
● Nogourani, MK; Janghourbani, M; Khadem, P; Jadidi, Z; Jalali, S. A 12-month clinical
●
●
●
●
evaluation of pit-and-fissure sealants placed with and without etch-and-rinse and selfetch adhesive systems in newly-erupted teeth. J Appl Oral Sci. 20 (3) Jun: 352-356,
2012.
Antonson, S; Antonson, D; Brener, S; Crutchfield, J; Larumbe, J; Michaud, C; Ruya
Yazici, A; Hardigan, P; Alempour, S; Evans, D; Ocanto, R. Twenty-four month clinical
evaluation of fissure sealants on partially erupted permanent first molars. J of the
American Dental Association. February 1st: 115-122. 2012
Gooch, B; Gray, S; Rozier, R; Fontana, M; Carter, N; Haering, H; Hinson, P; Mallatt, M;
Miller, W; Simonsen, R; Zero, D. Preventing Dental Caries Through School-Based
Sealant Programs. J of the American Dental Association. Nov: 1356-1365, 2009.
Bravo M, Montero J, Bravo JJ, Baca P, Llorda JC. Sealant and fluoride varnish in
caries: a randomized trial. J of Dental Research. Dec: 1138 – 1143, 2005
Geiger SB, Gulayev S, Weiss EI. Improving Fissure Sealant Quality: mechanical
preparation and filling level. J of Dentistry. Aug: 407-12, 2000
141
References
● Agrawal, A; Shigli, A. Comparison of six different methods of cleaning and preparing
occlusal fissure surface before placement of pit and fissure sealant: An in vitro study. J
of Indian Society of Pedo and Prev Dent. 30 (1): 51-55, 2012.
● Beauchamp, J; Caufield, PW; Crall, JJ; Donly, KJ; Feigal, R; Gooch, B; Ismail, A; Kohn,
W; Siegal, M; Simonsen, R. Evidence-based clinical recommendations for the use of
pit-and-fissure sealants: a report of the American Dental Association Council on
Scientific Affairs. Dent Clin N Am. 53: 131-147. 2009.
● Feigal, RJ; Musherure, P; Gillespie, M; Levy-Polack, M; Quelhas, I; Hebling, J.
Improved sealant retention with bonding agents: a clinical study of two-bottle and
single-bottle systems. J Dent Res. 79(11): 1850-1856, 2000.
● Fontana, M; Young, DA; Wolff, MS. Evidence-based caries, risk assessment, and
treatment. Dent Clin N Am. 53: 149-161, 2009.
● Ahovuo-Saloranta Anneli, Forss Helena, Walsh Tanya, Hiiri Anne, Nordblad Anne,
Mäkelä Marjukka, Worthington Helen V. Sealants for preventing dental decay in the
permanent teeth. Cochrane Database of Systematic Reviews 2013
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