Breast feeding and ECC

● Kotlow LA. Breastfeeding: a cause for dental caries in children. J Dent Child.1977; 44:192

Breastfeeding and the risk of early childhood caries.

White V.

Evid Based Dent. 2008;9(3):86-8.

Association between infant breastfeeding and early childhood caries in the United States.

Iida H, Auinger P, Billings RJ, Weitzman M.

Pediatrics. 2007 Oct;120(4):e944-52

Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent. 1999;21:86

● Conclusions1. Breast milk has a pH of 7.2

2. Proven health benefits of breastfeeding

3. Lack of consistent evidence

4. Promote breastfeeding

5. Emphasize OH and reduce CHO consumption

Ankyloglossia ● 6 week old healthy infant is referred to you for

problems with sucking. Pediatrician is concerned and noted a ‘short tongue’. Your examination reveals ankyloglossia.

● What do you tell the parent and pediatrician?● Is there any evidence to support treatment?● Evidence based decision:

‘ There are no controlled prospective trials for surgical interventions in infants with ankyloglossia, therefore there no conclusive suggestions regarding the method of intervention. Also controversial is which type of tongue-tie needs to be surgically repaired and which can be left to observe’

• How severe is the condition?• Is the infant having problems ‘latching’ on to the

mothers breast?• Is the infant gaining weight?

● 1. Cochrane Oral Health Group- nothing

● 2. ADA EBD: nothing

3. PubMed:

Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound.

Geddes DT, et al

Pediatrics. 2008 Jul;122(1):e188- 94.

4.NGCH-● 1.

Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Academy of Breastfeeding Medicine - Professional Association.  2004. 

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4

Pulp Therapy Mythology

5

Evidence for Pulpal Therapy

● With rare exception, the studies we rely on are academic thesis projects

● Almost all use the same inclusion criteria which really don’t reflect clinical reality

● Few follow their teeth through exfoliation and eruption of the succedaneous teeth

● Results are often clouded by purist views of radiologic success

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What’s the Evidence for Pulp Therapy?

Nadin G, Goel BR, et al. Pulp treatment for

extensive decay in primary teeth (Cochrane

Review). The Cochrane Library 2003;2:1-30.● Searched all languages, found 138 references, read

77 in entirety, and…● Three studies met criteria for inclusion!• Conclusion: Insufficient randomized trials to provide

reliable evidence supporting one type of pulp treatment as superior to others

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Common Clinical Situations

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What Evidence Exists On Diagnosis of the Primary Pulp

● Extent of Carious Lesions

● Tooth Coloration● Location of Tooth● Clinical, Radiographic

and Bleeding

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The Extent of Caries

The relationship between extent of carious involvement of the marginal ridge and pulp inflammation in primary molars MS Duggal, A Nooh, A High. J Dent Res Abs # 1540, 1999

Classified marginal ridge caries

Pulp changes identified in 80% of teeth with <2/3rd of ridge involved

Pulp changes in 100% of teeth with > 2/3rd of ridge involved

Part of UK guidelines for pulp therapy

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The Extent of CariesHistopathology of the pulp in primary incisors withdeep dentinal caries. Eidelman, E et al. Pediatric Dent 1992;14:372● Looked at 53 carious primary incisor pulps without x-ray or clinical

pathosis, but deemed unrestorable● Removed caries after these teeth extracted as one would do if they

were to be saved● Had carious exposures on 24

but not on 29 of these● Of 29 unexposed, only 6 were

histologically healthy pulps● None of the 24 exposed pulps were

histologically normal; two-thirds had coronal inflammation

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Are Dark Teeth Sick Teeth?• Sonis et al. Longitudinal study of discolored primary teeth and effect on succedaneous teeth. J Pedo 1987;11:247

● Followed 37 darkened incisors until lost and eruption of successor

● No clinical or x-ray pathosis on 72 percent

● Only 11 teeth with pathosis

● Only one successor had enamel problems; and successors tended to erupt early

• Soxman JA et al. Pulpal pathology in relation to discoloration of primary anterior teeth. JDC 1984;51:282

● Total necrosis in 11/23 and as early as 10 days S/P trauma

● No correlation between color and histopathological status

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Who Wins the Technique War?

Study Yr NTime

(mos)%

Clin%

Xray

Fei et al

‘91 83 12 96 96

Casas et al

‘03 182 24 96 61

Fuks et al

‘97 55 6-35 92.7 74.5

Smith et al

‘00 242 4-57 99 n/a

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Pulpectomies Work as WellTwo-year outcomes of primary molar ferricsulfate pulpotomy and root canal therapy.

CasasMJ et al. Pediatr Dent 2003;25:97● Studied 109 molar pulpectomies and they

were as good as ferric sulfate pulpotomies (98% after 2 years)

An evaluation of pulpal therapy in primaryincisors. Coll JA et al. Pediatr Dent 1988;10:178.● Studied 27 incisor pulpectomies and found

them 78% effective after 45.5 months

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Pulpectomy Research Support

Success rate of root canal treatment in primary molars.

Moskovitz et al J Dent (2005): 41-47 • Found 85% success rate with pulpectomy

procedure – Filled with IRM

Ballesio et al Eur J Pediatr Dent (2002) 133-140.Chemical and pharmacological shaping of necrotic

primary teeth. • Found 92% success rate

– Necrotic primary molars with fistulas– First visit: canals filled with powdered antibiotic

mixed with anesthetic solution– Second visit: canals were filled with IRM

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Who Has Time For This?

Coll J. Indirect pulp capping and primary

teeth: is the primary tooth pulpotomy out of

date? Pediatr Dent 2008;30:230-236.● This author recommends placement of GIC for This author recommends placement of GIC for

several months in primary teeth when caries several months in primary teeth when caries approaches the “red zone” approaches the “red zone”

● While he maintains this is cheaper than a While he maintains this is cheaper than a pulpotomy, he does not address cost of re-pulpotomy, he does not address cost of re-treatment which may be neededtreatment which may be needed

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Bring Back the Indirect Pulp Cap? Indirect pulp treatment of primary posteriorteeth: a retrospective study. Al-Zayer MA etal. Pediatr Dent 2003;25:29● Looked at 187 primary posterior teeth treated with

indirect pulp therapy● Deep dentinal caries, but no symptoms or x-ray

signs of pulpal pathosis● CaOH placed with crown, amalgam or composite● A 95% success with a 96% 1-year success● Crowns had best success

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What Else About Pulp Therapy?

If we look at what the many studies tell us….● Repeated studies suggest that regardless of medicament

treatment success depends on initial pulp health [inclusion criterion for all studies]

● First primary molars uniformly have poorer prognosis compared to second molars

● Most studies show either little difference in success between clinical and x-ray findings, or use clinically irrelevant criteria, so don’t radiograph without clinical signs

● Always follow pulp therapy with a crown

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Why Do a 5-Minute Full Strength FC Pulpotomy?Histobiological effectiveness of a reducedconcentration of Buckley’s formocresol. Verco PJ.Ped Dent 1985;7:130● Looked at S. faecalis, S. salivarius, Staph aureus● Found formocresol concentrations of 0.05 to 0.33%

to be bacteriocidalComparison of antimicrobial and cytotoxic effects ofglutaraldehyde and formocresol . Hill SD et al. O,O,O1991;71:89● Mean microbicidal concentration of formocresol

was 0.23% and cytotoxic concentration (fixation) was 0.0075%

● The minimum concentration of formocresol to kill 9 organisms was 0.75% for 2 minutes

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Confused? Me Too!

● Literature on FC, FS, MTA, laser, NaOCl, CH is often conflicting or does not track long enough to show a measurable difference to merit switching materials

• If what you use works, keep using it!

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So What Does the Evidence Say?

● Carious primary tooth with deep caries but no exposure, do an indirect pulp cap

● Carious primary tooth with stoppable pulpal hemorrhage and no other clinical or radiographic signs, do a pulpotomy

● Carious primary tooth with pulpal pathosis but good root structure (ie, no resorption) do a pulpectomy

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22

Restorative Care

23

Stainless Steel Crowns: Underused, Abused and Misunderstood

Longevity of crowns compared to amalgam demonstrated clearly by numerous studies

Author Amalgams

placed

Failures

#/(%)

SSCs

placed

Failures

#/%

Study

Duration

Braff 1975

150 131(87) 76 19(25) 2.5 yr

Dawson 1981

102 72(71) 64 8(13) 2 or more yr

Messer 1988

1177 255(22) 331 40(12) 5 yr

Roberts 1990

706 82(12) 673 13(2) 10 yr

Einwag 1996

66 38(58) 66 4(6) 8 yr

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Stainless Steel Crowns: Not Much Evidence on Technique

● Pre-crimped, pre-contoured crowns or do it yourself?

● Trimming crowns?● One brand versus

another?● Polishing before

cementation?● Type of cement used?● High occlusion?

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SSC Types3M (Ion)pre-crimpedpre-contouredpre-trimmedpre-ferred!

Uniteknot pre-crimpednot pre-contourednot pre-trimmed

2nd molar 1st molar