I. Introduction to Pediatric Restorative Dentistry

      A. Why do the primary teeth?

            1. Will be present until age 10-12

            2. They will be chewing food during greatest period of growth

            3. Interproximal caries can lead to space loss

      B. Why do the primary anteriors?

            1. They help to develop proper speech patterns

            2. Young children's self-esteem is often overlooked

      C. It's a great time to introduce dentistry to children before they freak out!

      D. Practice Builder

            1. Treat children well and their parents will stay with your practice

            2. Parents do for their children what they won't do for themselves

      E. Financially worthwhile

            1. With efficient operative, productivity can be high

            2. Get children caries-free and recalls are non-stressful production

            3. No lab bills

II. Philosophy of Modern Pediatric Restorative Dentistry

      A. Prevention

            1. Regular checkups

            2. Annual bitewings

            3. Fluoride treatments

                  a. Systemic supplements

                  b. Topical applications

            4. Sealants

      B. Conservative cutting of teeth

            1. Preservation to slow long-term progressive decline

            2. Air abrasion techniques

            3. Preventive resin restorations

      C. Attitude adjustment

            1. Positivism

            2. Sense of accomplishment

            3. High expectations

      D. Developmental Chart

III. Diagnosis

       A. Dental Development

             1. Age of patient and likelihood of retention

             2. Clinical mobility

             3. Condition of roots

       B. Radiographic

             1. 70% of lesions in primary teeth are interproximal

             2. Look at occlusals on permanent molars-- sometimes show in films

       C. Clinical appearance

             1. Is a "stick" a "treat" or a "no treat?"

             2. Which grooves are involved?

             3. What is patient's history (hygiene and caries activity)

       D. When do Class II's become stainless steel crowns?

             1. Main criterion is likelihood of Class II restoration failure

             2. If half of the clinical crown (or more) is broken down, it's a crown

             3. If more than 2 surfaces are carious, it's likely a crown

       E. Pulp therapy for primary teeth

             1. Pulpotomy

                  a. Consider age of the child and size of lesion

                  b. If clinical crown is "dished out," plan a pulpotomy

                  c. If caries are radiographically more than halfway to pulp, consider    

                      pulpotomy

                 d. Final decision is based on carious or mechanical exposure

                 e. Indirect pulp-capping is now shown to be successful in primary teeth

             2. Pulpectomy

                  a. Consider age of child and clinical condition of tooth

                  b. Maxillary anteriors and second primary molars are candidates

                  c. First primary molars are not good candidates

                  d. If the furcation area is involved, this is a poor candidate

             3. Anterior trauma

                  a. Usually requires no treatment

                  b. Darkening is actually normal, but not an indication

IV. Treatment Planning

       A. Must consider age of patient for length of visit

             1. Young children need shorter, earlier appointments

             2. Older children (6+) can handle longer, later appointments

       B. Number of visits

             1. Always try for 1 or 2 visits, with a maximum of 3-4

             2. Consolidate treatments during each visit

                  a. If space maintainers are needed, restore abutment at banding visit                              
                  b. If SSC and Class II restorations abut

                      i. For resins or ionomers, complete restoration, then crown

                      ii. For amalgams, complete crown first, then restoration

       C. Prioritizing

             1. Posteriors should always be treated first

                  a. Longevity of teeth

                  b. Chew food during child's growth

                  c. Less traumatic for treatment

                  d. Often NOT the parents' preference

             2. Anteriors should be saved for last                                

                  a. Function for speech and smiling are secondary to mastication

                  b. More difficult to treat comfortably

                  c. Incentive for parents to continue with treatment of posteriors

             3. Referral of abscessed teeth

                  a. Let oral surgeon complete care with general anesthetic

                  b. Have exodontia done out of your practice

                  c. Most likely procedure to install fear/bad experience

       D. Sequencing of treatment

             1. Generally start with mandibular arch first, if possible

             2. Try to relieve pain at first visit

             3. Save short, simple quadrant for last, as that memory will be held

V. Stainless Steel Crowns—prepping and crown placement

     A. Prep occlusal surface first with diamond wheel

          1. Reduce only about 1- 1.5 mm—remove occlusal anatomy

          2. Reduces hemorrhage by avoiding gingiva

          2. Gives better idea of crown size

     B. Prep axial walls with 1170 thin tapered fissure bur

          1. Minimal reduction, but break proximal contacts

          2. Use wedges to reduce hemorrhaging

          3. Can reshape prep to the shape of the crown

     C. Select crown size

          1. Should fit snugly, but must go all the way down

          2. Check for crown length- if tissue blanches, trim crown

          3. General rule is tissue should not blanch more than 1mm

     D. Shape crown

          1. Contouring pliers to basic curvature

          2. Crimping pliers to engage undercuts of prep

          3. With pre-crimped crowns, these steps are not necessary

     E. Cement crown

          1. RelyX Luting Plus cement

          2. ZnPO4 is OK

VII. Anterior Strip Crowns

     A. Isolate with rubber dam with individually punched holes (small)

     B. Alasticks

          1. Retract tissue and rubber dam

          2. Hemorrhage control

          3. Leave facial floss to facilitate removal of alastick

     C. Caries removal

          1. Slow speed round bur

          2. Vitrabond Plus in deep areas (+increases retention)

     D. Prep incisal and axial walls

          1. Minimal reduction

          2. 169 bur

     E. Fit strip crown forms

          1. Must trim away entire "cuff"

          2. Crown should fit snugly

          3. Vent holes in MI and DI angles

          4. Fill 1/2-2/3 full with Filtek Supreme Ultra A1D and condense

          5. Place over tooth

          6. Remove excess material and light

     F. Removing strip crown form

          1. Course disk to remove incisal edge

          2. Hollenbeck to "unzip" lingual

          3. Hemostat to remove strip crown

          4. Finish edges with Soflex disks

     G. Remove alasticks

VIII. Local anesthesia

A.    Infiltrations vs. Blocks

B.    Needles

1.  27 ga. short

2.  30 ga. short

3.  30 ga. extra short

C.   Septocaine 4%

1.  Especially effective for infiltrations

2.  NOT recommended for children under 3 years of age

3.  NOT recommended for mandibular blocks

4.  Effective for hard-to-get-numb patients

D.   Lidocaine 2%

1.  For children under 3 years of age

2.  For mandibular blocks

3.  Can be used for infiltrations, too

E.    Topical Anesthetic

1.  Caine sticks

2.  Can give to kids for soft-tissue extractions at home

F.    Safety techniques

1.  Assistant hands of child’s forehead and child’s hands

2.  Mouth prop

G.   Technique

H.   Management

I.      Vocabulary

J.     Onset

1.  Local anesthetic buffering technique

2.  Onset of anesthesia usually under 2 minutes

3.  Must be prepared immediately prior to injection

K.   Oraverse

1.  Vasodilator

2.  Reduces anesthetic duration by half

IX. Treatment of Posteriors

       A. Primary- Class I and II Restorations

             1. Materials             

                  a. SonicFill packable composite

                  b. Amalgam

             2. Preparations

                  a. Conservative

                  b. Use 330 burs/rounded line angles

             3. Use wedges

                  a. Reduces hemorrhaging

                  b. See prep at contact point more clearly

        B. Permanent- Preventive Restorations

             1. Materials

                  a. Heliomolar

                  b. Amalgam

             2. Preps

                  a. Preventive resins

                  b. Traditional alloy preps

X.  Primary anteriors

       A. Cl. III and Cl. V

             1. Preps (330 bur)

             2. Dyract

XI. Pulpotomy on Primary Teeth

       A. If exposure occurs, open with any bur into chamber

       B. Debride coronal pulp with sharp #8 round bur

       C. For ferric sulfate, countersink into radicular chambers with next smaller bur

       D. Hemostasis with dry cotton pellets

       E. Fix pulp stumps with Ferric Sulfate or Formocresol

       F. Place ZOE packing

XII. Pulpectomy

       A. Open with any bur into chamber

       B. Debride chamber

             1. Similar to permanent tooth-- use files

             2. Use sweeping motion for posteriors

             3. Not nearly so meticulous as permanent preparations

       C. Rinse with hydrogen peroxide

       D. Fill chambers

             1. Vitapex (CaOH and iodoform paste)

             2. Add powder to ZOE and hydraulically condense

       E. Post-op film to confirm fill

XIII. Paraphernalia

       A. Mouth prop

            1. Extends treatment time by reducing fatigue

            2. Enables better access for restorative care and injections

            3. Avoids biting of provider and handpieces

       B. Rubber dam

            1. Use slit, not individual holes

            2. Essential for bonding and sealants

       C. Clamps

            1. Maxillary teeth

                  a. Permanent molars= 3, 14, 14A, W5

                  b. Primary second molars= 3, 8A, W5, W8

                  c. Primary first molars and biscuspids= 2

            2. Mandibular teeth

                  a. Permanent molars= 3, 14, 14A

                  b. Primary second molars= 8A

                  c. Primary first molars and bicuspids= 2

XIV. Sealants

A.  90% of permanent tooth caries are in sealable grooves

B.  Combination bonding agent with filled sealant material improves sealants

C. Technique

1. Isolate teeth

             2. Clean with air abrasion

 3. Etch for 5-10 seconds

 4. Rinse and dry (but not desiccate)

 5. Place unfilled bonding agent into grooves

 6. Lightly air dry (but do NOT cure)

 7. Place filled sealant material

 8. Cure everything at once

Mouth props/HuFriedy                                                        Caine tips

Ferric Sulfate/Ultradent/Direct only                                 Clamps/Ivory    

     Astringident 15.5% Fe(SO4)                                           W5 and W8 for Dyclone

                                                                                                  8A, 3 & 14A for anesthetic

Rubber dam/Hygienic                                                          Gray Alastics/Unitek/3M

Suggested List

Ultra-Seal XT/Ultradent/Direct only                                 RelyX luting cement/3M  

    with 35% Ultra-etch and Primadry                                    cementing crowns

Filtek Supreme Ultra A1D (3M)                                        Wedges/Premier

Heliomolar/Vivadent                                                            Dyract/Caulk

Anterior strip crowns/3M                                                    Unitek SSC's/Unitek/3M

APF Topical Fluoride Foaming Solution/Oral-B             Vitapex filling material                  

Crystal Mark Air Abrasion unit                                         Matrix bands/Denovo/direct

Flavored N2O nosepieces/Accutron                                   30G X-short/Astra

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