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Is It Time to Be Conservative, or Progressive? by Jarod Johnson, DDS

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Header: Is It Time to Be Conservative, or Progressive?
by Jarod Johnson, DDS

When planning restorative treatment for primary teeth, the variation in anatomical structures makes conventional restoration a challenge. One of the most important factors to consider, in my opinion, is that primary teeth have thinner enamel and less-mineralized dentin and enamel, which means that carious lesions can progress more rapidly. Mineralization also plays an important role in the ability to bond dental restorations in primary teeth, so primary teeth are weaker in supporting restorative materials.1

Many restorative materials can be utilized for primary teeth. Glass ionomers, resin-modified glass ionomers, amalgams, composites and stainless steel crowns have proven efficacy, and preveneered resin stainless steel crowns and prefabricated zirconia crowns are also quickly gaining popularity in the pediatric community.2

Treatment planning
In my mind, the common misconception that "baby teeth will just fall out anyway" is juxtaposed with the concept of conservation of tooth structure, now provided by advances in modern materials. I was taught that the conservation of tooth structure should be secondary to the need to re-treat a primary tooth; this was difficult for me to grasp initially, but I quickly learned in residency that this philosophy held very true in primary dentition. Many high-risk children I had seen the previous year would return with decay on another surface of the tooth that had just been restored, which meant another operative appointment with anesthesia (probably on a nervous or apprehensive child). In many situations, treatment with a crown would have prevented a second visit and saved money.

This juxtaposition also exists in Class I and Class II lesions; however, advances in composites also allow for a more conservative approach. When placing amalgam in the primary dentition, the traditional GV Black extension for prevention can provide a benefit to the patient. Preparing all decayed, stained or uncoalesed fissures will help reduce the need to re-treat a tooth because of new decay in any untreated fissures.

Composite materials provide a distinct advantage, because a more conservative approach can be utilized—providers can prepare only the decayed portion of the tooth, then use a flowable material or sealant on the rest to provide the same benefits that extension of the preparation would have applied. Both approaches will help reduce the chance that a tooth will need to be re-treated because of new carious lesions in the grooves of the same tooth.

There's a variety of philosophies on treatment-planning for Class II lesions in the pediatric field—specifically in regard to lesions that are apparent on radiographs. Again, enamel thickness of primary dentition is less mineralized and thinner than that of permanent dentition—1mm, compared with 2mm.2 This means lesions will progress more quickly; deciding when to treat and when to attempt remineralization can be difficult. If adjacent teeth are being treated, this may provide the clinician with direct visualization to aid in making the decision, and if anesthesia is provided in the same region, a caries biopsy could be performed to determine the path for teeth in other quadrants. Patients at high risk for caries may also benefit from a more aggressive treatment plan. Class II lesions that are clinically visible should be given high consideration for stainless steel crowns as a restorative material unless the tooth is near exfoliation.

Fig. 1

Materials options 3
The variety of available materials provides multiple options for restoring primary teeth. Glass ionomers are suitable for Class I restorations and sedative fillings, and their ability to bond to dentin makes them advantageous in interim therapeutic restorations/atraumatic restorative techniques. While resin-modified glass ionomers have the same types of indications for use, their resin component gives them greater wear resistance than traditional glass ionomers. This allows them to be used in Class II preparations.

Amalgam restorations have been used for many years in primary dentition. They can be utilized in Class I and II restorations as well as posterior Class V restorations, and some providers use them for Class III lesions on the distal lingual surfaces of primary canines. It may be advantageous for providers to use a quick-setting alloy when working with children, to help reduce chair time.

Composite restorations have the most versatile use in primary dentition. They offer high esthetics and can conserve more tooth structure than other restorations. They can be applied to Class I, II, III, IV and V restorations, and strip crowns may be considered for Class III and IV restorations where restoration retention may be of concern.

Stainless steel crowns should be considered for high-risk caries patients, teeth with three or more surfaces of decay, primary first molars with Class II lesions on mesial surfaces, clinically visible Class II carious lesions of posterior molars (when the lesion expands greater than one-third the intercuspal distance), patients with recurrent decay on multisurface restorations, patients with hereditary enamel and dentin defects, hypoplastic molars with carious lesions, and patients treated under sedation or general anesthesia.

Crowns made of resin-veneered stainless steel or preformed zirconia are gaining popularity quickly in pediatric dentistry. Their indications are similar to those for stainless steel crowns, and they're most commonly used to restore anterior teeth in primary dentition. They offer greater esthetics, but preparation is more technique-sensitive than traditional stainless steel crowns, and increased cost may discourage some providers from using them in clinical practice.

Fig. 2
Fig. 3
Fig. 4
Fig. 5
Evidence-based dentistry
It's also important to consider success rates when choosing a restorative material. Numerous studies have looked at the effectiveness of materials for multisurface carious lesions. In a two-year study that compared the use of amalgam, resin-modified glass ionomer and composite in Class II restorations, a higher proportion of composite restorations (47 percent) ended up with radiographic defects than amalgams (11 percent) or resin-modified glass ionomers (13 percent). The authors suggested that composite should be used in teeth that are expected to exfoliate within two years.4

Similar findings were evident in The New England Children's Amalgam Trial—composite restorations were more affected by recurrent decay, and were seven times more likely than amalgam to need repair. The study found that children who needed multiple restorations on initial presentation were more likely to have recurrent decay. This helps support the idea that high-risk children may benefit from the use of stainless steel crowns.5

A systematic review comparing Class II amalgam restorations to stainless steel crowns, which included 10 prospective studies, found that amalgams were replaced from 1 1/2 to nine times more frequently than stainless steel crowns.6 A literature review published in 2002 combined results from five studies that compared the use of amalgam and stainless steel crowns for multiple surface lesions in primary teeth. The study showed failure rates of 26 percent for amalgam and 7 percent for stainless steel crowns, with a median study length of five years.7

Practitioners currently benefit from a wide variety of restorative materials that can be utilized for the primary dentition. Selecting the correct material and preparation design based on each patient's individual needs, with a focus on caries risk, can help reduce future treatment needs and provide a cost savings to patients.

References
  1. Lee, J. (2002). Restoration of primary anterior teeth: review of the literature. Ped Dent , 506-510.
  2. Casamassimo, Fields, McTigue, & Nowak. (2013). Pediatric Dentistry: Infancy Through Adolescence. St Louis: Elsevier Saunders.
  3. American Academy of Pediatric Dentistry. (2015). Guideline on Restorative Dentistry. Ped Dent , 232-243.
  4. Fuks, A., Araujo, F., Osorto, L., Hadant, P., & Pinto, A. (2000). Clinical and radiographic assessment of Class II esthetic restorations in primary molars. Ped Dent , 479-485.
  5. Soncini, J., Maserejian, N., Trachtenburg, F., Tavares, M., & Hayes, C. (2007). The longevity of amalgam versus compomer/composite restorations in posterior primary and permanent teeth. J Amer Dent Assoc , 763-772.
  6. Randal, R., Vrijhoef, M., & Wilson, N. (2000). Efficacy of preformed metal crowns vs amalgam restorations. J Amer Dent Assoc , 337-343.
  7. Randall, R. (2002). Preformed metal crowns for primary and permanent molar teeth: review of the literature. Ped Dent , 489-500.




Dr. Jarod Johnson Dr. Jarod Johnson earned a bachelor's degree in biomedical engineering in 2009 and his Doctor of Dental Surgery in 2013, both from The University of Iowa. In June 2015 he completed the advanced education program in pediatric dentistry at the School of Dental Medicine at the University of Nevada, Las Vegas. While in Nevada, Johnson was a delegate in the Southern Nevada Dental Society to the Nevada Dental Association. He recently opened a private practice in Muscatine, Iowa.



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