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JADA Specialty Scan - Pediatric Dentistry
Pediatric DentistryJADA Specialty Scan

Guiding children through dental care

Communication techniques and pharmacological management trump aversive techniques when it comes to effectively managing children’s behavior during dental treatment. It is important information because “behavior management is the cornerstone for the success of pediatric dentistry in managing children,” according to an award-winning essay on the topic.

Published in the January-April 2015 issue of the Journal of Dentistry for Children, the paper reports on evolving, contemporary and aged behavior management methods and their practical applications.

The report says that although guidelines and suggestions are published by prominent pediatric organizations, techniques used in contemporary clinical practice are dependent on distinct circumstances, including the individual child and cultural context.

Tell-Show-Do (TSD), nonverbal communication and voice control, reinforcement techniques, modeling, distraction, temporary escape, restraint and pharmacological methods are among those described as within the continuum of contemporary behavioral management techniques. Implementing such methods for optimal efficacy is explained.

For example, modeling is most effective when models are of similar age or children perceive them to have prestige or status. Restraint may be indicated for patients who require emergency treatment and are unable to cooperate due to disability or for sedated patients to decrease unwanted movement. The use of a stop sign motion is the most common method of allowing the patient what’s called temporary escape.

The literature review also discusses modern alternative techniques. “These techniques do not replace the ‘old’ strategies but add to the armamentarium available to the pediatric dentist,” according to the review. They include child-centered care, magic tricks, hypnosis, memory restructuring strategy and motivational interviewing. Methods rarely used anymore are parental presence/absence and clinicians’ hand-over-mouth.

The literature review showed that changing parenting styles, as well as changes in society and in dental education are among factors influencing changes in behavior management methods.

“Techniques utilized by the dental team in developing the child’s cooperative ability, behavior and coping strategies have changed over the last 50 years, reflecting the changing nature of parenting, what society deems is acceptable and the philosophies and education of contemporary pediatric dentists,” authors reported.

Among conclusions they said, “Techniques that are acceptable in contemporary clinical pediatric dentistry aim to establish communication, reduce anxiety and guide a child through the complex social context of dentistry in a positive manner.”

Read the original article.


Consulting Editor: Paul S. Casamassimo, DDS, MS
Professor of Pediatric Dentistry,
The Ohio State University College of Dentistry and Nationwide Children's Hospital, Columbus, OH

Consulting Editor: Arthur J. Nowak, DMD
Professor Emeritus, University of Iowa College of Dentistry
Affiliate Professor, University of Washington School of Dentistry

Dental amalgam and primary teeth

Long controversial, dental amalgam has been widely investigated since its introduction in the western hemisphere in the 1830s. The March/April 2015 issue of Pediatric Dentistry summarizes current insights on the pros and cons of its use for pediatric patients. The author examines emerging news about effectiveness, advantages and disadvantages, as well as knowledge gained through the decades from around the world.

The author, from Hebrew University, makes four recommendations about using dental amalgam based on review of the literature. They support the safety and efficacy of dental amalgam for all segments of the population, including the primary teeth for:

  • Class I restorations in primary and permanent teeth.
  • Two-surface Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles.
  • Class II restorations in permanent molars and premolars.
  • Class V restorations in primary and permanent posterior teeth.

Among reported advantages of dental amalgam as a restorative material is its station as the only restorative material in which the marginal seal improves with time. As explained in the paper, “This is mainly due to the acid environment and low oxygen concentration in the space between the tooth and the restoration, leading to corrosion. In former-generation amalgam (low copper), the gamma two phase was formed and slowly filled the aforementioned space, creating the marginal seal.”

The report explores four main prevailing concerns about dental amalgam. Each is related to the potential toxicity of mercury and the effects of: (1) inhalation of mercury vapor or amalgam dust; (2) ingestion of amalgam; (3) allergy to mercury; and (4) environmental considerations.

Dental personnel have been found to excrete greater amounts of mercury in their urine than a control population when the handling of mercury and amalgam was inappropriate. However, all estimates of daily total amalgam-associated mercury intake from dental fillings produced by chewing are well below the health hazard threshold from mercury exposure in the general population. Animal and human studies have not demonstrated any association between amalgam fillings and birth defects, though mercury can pass from mother to fetus and may be detected in the milk.

The author broaches conflicting outcomes and controversy generated from research on a wide range of issues. For example, two clinical studies on the safety of restorations found higher mercury levels in children who received amalgam than resin composites. Follow-up periods were five and seven years. However, scientists following up at five years found no statistically significant differences between the groups in terms of change in IQ score, four-year change in general memory index, visual motor composite score or urinary albumin levels. The study that followed up at seven years showed higher urinary mercury levels among the children who received amalgam, but there were no statistically significant differences between the groups’ scores on neurobehavioral assessments of memory, attention/concentration or motor/visual-motor performance.

Another researcher subsequently criticized the studies, saying that although both provide important data, the delayed effects of early toxic exposure later in life are not addressed in these reports.

Read the original article.


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Restoring primary anterior teeth

An update on clinical recommendations for restoring primary anterior teeth calls attention to the continued lack of supporting clinical data on techniques and materials. The conference paper was published in the March/April issue of Pediatric Dentistry.

Following up on 2002 research, the author uncovered little new evidence since that time. Because of insufficient controlled clinical data to suggest one type of restoration is superior to another, he asserts from the outset of the report that any policy statement on the topic will be based largely on anecdotal evidence, clinical experience and expert opinion, rather than well-controlled scientific data.

“The continued discussion and search for good esthetic restorative options for compromised primary anterior teeth is necessary and even more of a concern in 2014 than it was in 2002,” said the author, noting increasing demand among parents for ever-improving esthetic solutions.

“One need only consider the population of patients that require these restorations to develop a list of obstacles,” said the author about the feasibility of designing and completing needed studies. Difficulties, including the young age of the children, obtaining parental consent, cost of treatment, reluctance on the part of the clinician, compromised esthetics, variability in the amount of remaining tooth structure and differences in caries risk may all be obstacles to obtaining good clinical data on restorative options for primary incisors.

Among discussion topics, he emphasizes awareness of strengths, weaknesses and properties of each material to enhance the clinician’s ability to make the best selection for each individual situation. “Operator preferences, esthetic demands by parents, the child’s behavior, the amount of tooth structure remaining and moisture and hemorrhage control are all variables that affect the decision and ultimate outcome of whatever restorative solution is chosen.”

However, in the section discussing material selection for anterior primary teeth, the author said, “With the vast number of esthetic materials available today, there should be little or no reason to ever consider using amalgam for the restoration of primary incisors.”

Conclusions on the restoration of primary anterior teeth and recommendations for anterior restorations are presented in the paper.

Read the original article.


An update on RBC usage

Researchers updated recommendations for the use of resin-based composites (RBCs) in children and published their findings in the March/April 2015 issue of Pediatric Dentistry.

A consensus conference framed the discussion that focused on contemporary use of RBCs, including clinical factors such as risk assessment. Authors stress that the use of RBC is a critical component of pediatric restorative dentistry, with greater than 80 percent of dentistry attributed to pit and fissure caries.

“The overwhelming success of the preventive resin restoration makes it the treatment of choice for occlusal pit and fissure caries if the tooth can be adequately isolated,” researchers noted.

The authors discuss research that highlights the effectiveness of Class II restorations and indirect RBC restorations and define factors that make children poor candidates for RBC restorations. In addition, teeth that cannot be isolated to prevent saliva contamination or restorations that are extensive should have restorative materials other than resins considered, authors said.

Among downsides, the problem of resin polymerization shrinkage remains, according to the report, “and will continue to be a negative factor until RBC systems are developed that have negligible shrinkage during polymerization.” Wear has been a concern since traditional resins came to market. Authors reported that while contemporary RBCs have improved wear properties, they can still exhibit wear characteristic that are associated with factors including occlusal contract attrition, resin matrix fracture, chemical erosion and the degree of polymerization.

“Although contemporary RBCs have vastly improved from the original marketed composites, there is potential for further improvement,” authors said about future research. Indications and contraindications for using RBCs are outlined.

Read the original article.

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Help parents prevent childhood caries

Parents need to know the two most important facts about early childhood caries: that decay can harm primary teeth and that decay is preventable. “Tooth Decay in Baby Teeth: Baby Teeth Can Get Cavities” is an ADA brochure that puts these facts front and center.

“Tooth Decay in Baby Teeth” teaches parents which damaging habits to avoid, such as constant sipping on the go or in bed. Photos of stages of decay make a strong visual impression. The brochure includes home care tips and the caveat that babies should see a dentist before their first birthday.

The brochure layout can be viewed on this page. The eight-panel brochure comes in packs of 50; a personalized version and a Spanish version are also available. To order, call 1-800-947-4746 or go to adacatalog.org. Readers who use the code 15418E before July 17 can save 15 percent on all ADA Catalog products.


Do you see a lot of children in your practice?

American Academy of Pediatric Dentistry has the resources available for you to brush up on pediatric dentistry. Visit the Education Passport to see a variety of content focused on treating children. Topics include: behavior guidance, restorative dentistry, sedation, antibiotics and much more. Anyone can create a login to view and purchase content from our AAPD 2015, Preconference courses, CE Courses and webinars. Check it out today!


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What is Specialty Scan?

This is one in a series of quarterly newsletters updating dentists on selected specialties in dentistry. Information presented is aggregated and summarized from previously published materials, each item attributed to its publication of origin. This issue of JADA Specialty Scan focuses on pediatric dentistry, the second in the series on this topic for 2015. Other Specialty Scan issues are devoted to endodontics, oral pathology, oral and maxillofacial radiology, orthodontics, periodontics and prosthodontics. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. We welcome feedback on this and all Specialty Scan issues.

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Any statements of opinion or fact are those of the authors and do not necessarily reflect the views of the American Dental Association. Neither the ADA nor any of its subsidiaries have any financial interest in any products mentioned in this publication. Any reference to a product or service, whether in advertisements or otherwise, is not intended as an endorsement or as approval by the ADA or any of its affiliated organizations unless accompanied by an authorized statement that such approval or endorsement has been granted.

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