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John Zimmer, DDS R. Patrick Sewell, DMD

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1 John Zimmer, DDS R. Patrick Sewell, DMD
Caries Stabilization Caries stabilization can increase our treatment options for babies and young children. Caries stabilization can also make restoration of Early Childhood Caries (ECC) a positive experience for young patients and their parents. John Zimmer, DDS R. Patrick Sewell, DMD

2 Caries Stabilization Interim therapeutic restorations (ITRs)
Resin and glass ionomer sealants Regular recharging of ITRs and sealants with fluoride Fluoride varnish applications Twice daily brushing with fluoride toothpaste Caries stabilization involves using fluoride-releasing glass ionomer for interim therapeutic restorations (ITRs), resin and glass ionomer sealants to protect pit and fissures on primary molars, and regular recharging of ITRs and sealants through fluoride varnish applications, and twice daily use of fluoride toothpaste at home.

3 ECC Initiative Caries stabilization is a key component of the IHS Early Childhood Caries Initiative. With the implementation of this initiative, medical and community partners will be applying fluoride varnish and referring babies and young children to the dental clinic. Dental staff need to be ready to treat the first incidence of dental caries, often only one or two small lesions on the anterior teeth. Caries stabilization can be an important tool in providing clinical treatment for these patients. 3

4 Why Caries Stabilization?
Poor Dental Access for 0-5 year olds Only 10% of 0-2 year olds are seen yearly in the dental clinic. Only 25% of 3-5 year olds are seen yearly in the dental clinic. At this time only 10 percent of 0-2 year olds and only 25 percent of 3-5 year olds are seen yearly in the dental clinic. The 1999 Oral Health Survey of American Indian/Alaska Native dental patients found that 79 percent of children between the ages of 2-5 years had experienced dental caries, and 68 percent of this age group had untreated decay at the time of the dental examination. Caries stabilization can improve access, provide early intervention and treatment of ECC, and postpone definitive dental treatment until children are older and more cooperative. Many of these restorations may even last the lifetime of the primary tooth. 4

5 Objectives Indications for interim therapeutic restorations (ITRs), and glass ionomer sealants Appropriate technique for placing ITRs and GI sealants Variables that influence the success of ITRs and GI sealants Behavioral management when working with young children Oral health messages for parents and caregivers of young children Strategies for follow-up and coding The purpose of this course is to provide information about caries stabilization. This course will include: Indications for interim therapeutic restorations (ITRs), and glass ionomer (GI) sealants Appropriate technique for placing ITRs and GI sealants Variables that influence the success of ITRs and GI sealants Behavioral management when working with young children Oral health messages for parents and caregivers of young children Strategies for follow-up and coding

6 Policy Statement Download AAPD policy on ITRs.
The AAPD recognizes ITR as a beneficial provisional technique in contemporary pediatric restorative dentistry. ITR may be used to restore and prevent caries in young patients, uncooperative patients, patients with special needs and situations in which traditional cavity preparation and restorations are not feasible. According to the American Association of Pediatric Dentistry, interim therapeutic restorations (ITRs) are recommended to restore teeth and prevent caries in young patients, uncooperative or special needs patients, or in situations in which traditional cavity preparation and restorations are not feasible. Given the overwhelming cases of ECC presenting in IHS and Tribal dental programs, ITRs are a viable option to treat and manage ECC. Download AAPD policy on ITRs.

7 Indications for ITRs No pulpal involvement 1 or 2 surface lesions
Reduce fear Defer treatment Provide care at schools ITRs are not intended to replace conventional dentistry, and ITRs require both a proper diagnosis and good clinical technique. Indications for ITRs include teeth where there is no pulpal involvement and for teeth with one or two surface lesions. ITRs are often effective in helping children be less fearful because it can defer definitive treatment until the child matures or is referred to another provider. ITRs can also be used in settings like Head Start centers and schools where conventional cavity preparation is not possible.

8 Contraindications for ITRs
Necrotic pulp Irreversible pulpitis 3 or more surfaces affected by decay ITRs are contraindicated if a tooth has a necrotic pulp, irreversible pulpitis, or has 3 or more surfaces affected by decay.

9 GLASS Ionomer (GI) Materials
Bonds with tooth Remineralization Bacterial reduction Within dentin Oral environment It is no secret that a sealed margin is vital in restorative dentistry regardless of which material or procedure we use. What we want to achieve in caries stabilization is a way to restore and protect teeth in young children, plus reduce caries-causing bacteria within the oral environment. It is like extinguishing a fire through suffocation. Using a glass ionomer material for ITR creates a bond with the tooth to seal margins while releasing fluoride, and at the same time reduces cavity producing bacteria in the oral environment. Keep in mind that if we apply the same principles of ITR but use an ZOE restoration we can expect a much lower success rate (67% as compared to 92% with glass ionomer products) because of the poor marginal seal associated with ZOE. It is reported that using glass ionomer for caries control for 1-3 months is reliable 98% of the time.

10 Interim Therapeutic Restorations: Anterior Teeth
Let’s look at a couple of cases where we used interim therapeutic restorations. This is Michael who presented with cavitated lesions on his anterior teeth.

11 Interim Therapeutic Restorations: Anterior Teeth
We conservatively removed debris and some diseased tissue with a small spoon excavator.

12 Interim Therapeutic Restorations: Anterior Teeth
After rinsing and drying the tooth, we applied cavity conditioner and placed the glass ionomer material into the tooth.

13 Interim Therapeutic Restorations: Anterior Teeth
The results are esthetically acceptable. The restoration has a limited life span, but so does the tooth. It is important to tell parents the restoration is temporary and that it needs to be checked and recharged with daily use of fluoride toothpaste and fluoride varnish applications every 3 months. To demonstrate what this involves we then apply fluoride varnish to all the surfaces of the teeth.

14 Interim Therapeutic Restorations: Posterior Teeth
Interim therapeutic restorations can also be used on posterior teeth. Amber presents in the dental clinic with a lesion on the lower left quadrant. She is unable to tolerate films so bitewing radiographs are not available.

15 Interim Therapeutic Restorations: Posterior Teeth
Because caries tend to create bilateral lesions, we also check the lower right quadrant. When we point out the developing caries in that quadrant, the parent agrees that we need to treat both quadrants.

16 Interim Therapeutic Restorations: Posterior Teeth
After the lesion on the lower left is appropriately debrided, we use cotton rolls in a holder to isolate the teeth as we use cavity conditioner. Because Amber was cooperative, we took the opportunity to also apply cavity conditioner to the occlusal surface of the second primary molar to prepare it for a glass ionomer sealant.

17 Interim Therapeutic Restorations: Posterior Teeth
Notice Amber’s eyes. She is looking in a hand mirror watching as we place the glass ionomer. She is engaged and does not appear fearful. Although we cannot expect every patient to be this cooperative, caries stabilization techniques are virtually pain free. We can feel confident that we are building positive early experiences with dental treatment.

18 Positive Experience Because Amber remained cooperative, we also placed sealants on the first and second primary molars on the lower right quadrant, and applied fluoride varnish to all the teeth. This could be considered definitive treatment until bitewing radiographs are available. We explained to the parent that what we did today was temporary. We asked Amber’s parents to brush her teeth twice a day with fluoride toothpaste because fluoride release is significant for only about 72 hours. We also need to recharge the teeth with fluoride varnish treatments every three months.

19 Caries Stabilization Michael and Amber benefited from caries stabilization. Their dental treatment was quickly completed without local anesthetic, and they had positive dental experiences. ITRs, sealants, and fluoride varnish are procedures that can easily be done by general dentists and their staff. By incorporating caries stabilization in our practices we are able to increase access for young children who traditionally may not be seen in the dental clinic until there is severe decay. Through caries stabilization we can provide early intervention to prevent severe ECC.

20 ITR Technique Steps Now let’s talk about the clinical technique to provide ITRs. We have provided a copy of the ITR handout. We suggest downloading and printing it to be able to follow the step-by-step techniques.

21 Step 1: Examination and Diagnosis Children 6-24 months
When examining and treating young children age 6-24 months old, we recommend using knee-to-knee positioning. Notice the hand and elbow position of the parent. This is to enable the parent to gently hold a child’s arms. This reassures the child, and keeps the child from interfering with treatment. This can be done sitting in two straight-back chairs with knees touching or it can be done in the dental clinic using a dental chair. The knee-to-knee positioning make take a little practice to become comfortable using, but is worth the effort. Here are a few suggestions that are helpful when using knee-to-knee positioning: Explain what we are going to do and why, and answer any questions before the appointment, and before the child is reclined. Hand the child something to amuse and distract. If a child is given a toothbrush it can be used as a mouth prop and also to show how to clean the child’s teeth. After leaning the child back we may need to comfort the child by gently bouncing the child on our knees. Keep the visit short (5-10 minutes at the most).

22 Step 1: Examination and Diagnosis Children 2 years and older
Need photo When examining and treating children older than 2 years of age, we position the child in the dental chair so we are able to work from the 8 or 12 o’clock position or we use the knee to knee technique. A toothbrush or a hand mirror can be an effective distraction. Also, this age group usually responds well if they can see what we are doing.

23 Step 1: Examination and Diagnosis
No pulpal involvement One or two surface lesions As mentioned previously, ITRs are appropriate for teeth with one or two surface lesions with no pulpal involvement. If a tooth shows signs and symptoms of irreversible pulpitis, necrosis, or decay involving more than two surfaces, then ITRs will fail.

24 Step 2: Explanation Limitations Benefits
As with any dental treatment and especially treatment involving children, we need to explain our diagnosis to parents by showing them the condition of their child’s teeth. We then are able to give details about what can and cannot be done. Be sure to clarify that ITRs slow the penetration of caries, prevents sensitivity, and improves esthetics. ITRs absorb and leach fluoride, so daily brushing with a fluoridated toothpaste and regular recall visits increases their longevity. We also emphasize that ITRs can be done without using high speed drills and a local anesthetic.

25 Step 3: Tray Set-Up Instruments Materials Supplies
Proper preparation produces peak performance. As with any dental procedure, having the correct set-up of instruments, materials, and disposables is important. We only have a minimum amount of time to treat a young child, and we do want to be efficient. To prepare a tray set up for ITR, we need to have the following instruments, materials and supplies. Instruments: Mirror, small spoon excavator. Materials: Cavity conditioner, autocure glass ionomer, fluoride varnish. Supplies: Micro applicator brush, 2X2 gauze, cotton rolls. Be sure to choose a fluoride-releasing glass ionomer product, and it is critical to remember to use cavity condition which is not the same as phosphoric acid used to etch teeth.

26 Step 4: Excavation Partial excavation is probably the most difficult change we faced when incorporating ITR into a practice. Every restoration seals in bacteria even if aggressive excavation is used. A study conducted by Ricketts, Kidd, Innas and Clarkson showed that there is no detriment with partial excavation. Not every ITR preparation will have perfect margins because it is difficult to place a band and wedge if the area is not anesthetized. Still it is important to have the margins free of caries before placing the glass ionomer.

27 Incomplete caries removal: 40 month follow-up study
Initial placement months months months ITR is not a technique exclusive to the primary dentition as shown in a study by Maltz et al. These radiographs were taken at the initial time of ITR placement, and at 6, 18 and 38 months. If you look at the four radiographs over the 40 months, there is little to no change in the depth of the lesion. This technique may offer an option to extraction for children who have severely decayed permanent molars. Maltz et al. Caries Research 41: 27

28 Step 5: Isolate The next step is to isolate the teeth by using cotton rolls in a holder.

29 Step 6: Conditioner Step 6 is to apply cavity conditioner for 15 seconds, and then remove the conditioner by wiping the tooth with a 2x2 gauze square. Because the conditioner (carboxylic acid) is a component of the glass ionomer material, it is not critical that the conditioner be meticulously removed

30 Step 7: Placement Step 7 is to place glass ionomer material into the tooth.

31 Step 7: Placement Some dentists like to put a thin coat of Vaseline over the finished restoration to keep it from absorbing moisture. This is probably not necessary, however, because we are going to apply fluoride varnish.

32 Step 8: Fluoride Varnish
Step 8 we apply fluoride varnish to every surface of every tooth.

33 Step 9: Provide Parent Education
When clinical treatment is complete, we provide patient education. We reiterate that we have placed an interim therapeutic restoration that might last the life of the primary tooth. We stress the importance of recharging the restoration twice daily with fluoride toothpaste and regular fluoride varnish applications. We encourage follow-up visits as appropriate. Ideally, children with ITRs should be recalled every 3-6 months to check ITRs and apply fluoride varnish.

34 Factors for Success Proper diagnosis Adequate restoration
Appropriate excavation Margin quality Keep in mind four factors for success when placing ITRs. Proper diagnosis is key. ITRs are appropriate for teeth with one or two surface lesions with no pulpal involvement. If a tooth shows signs and symptoms of irreversible pulpitis or a necrotic pulp, or if the decay involves 3 or more surfaces, ITRs will fail. Providing an adequate restoration is as important as proper diagnosis. For example, decay in primary first molars is either very small on the distal making access difficult or the entire distal wall is affected and retention of ITR is difficult. In either scenario, the ITR restoration may be inadequate for the needs of the patient. Appropriate excavation is also a critical factor but may be a misnomer because there is no published evidence that aggressive excavation improves the pulpal healing response. A second primary molar will be difficult to excavate any decayed dentin because of the amount of sound occlusal enamel. Typically food is impacted in the lesion that we must remove, but we do not excavate dentin.  In either case, we do not aggressively excavate the decayed dentin and subject the irritated pulp to needless aggravation. A sound margin is more significant in the treatment outcome than aggressive excavation. Usually it is relatively simple to obtain a clean and dry margin on solid enamel until the glass ionomer cure is complete.

35 Interim Therapeutic Restorations
Before After In summary, using ITRs allow us to provide treatment to young children without a local anesthetic. The glass ionomer material produces a bond to enamel, releases fluoride, and reduces caries-causing bacteria within dentin and the oral environment in spite of moderate dentinal excavation. Now let’s talk about another component of caries stabilization: glass ionomer sealants.

36 Glass Ionomer Sealants
We know that over 50% of AI/AN children, ages 2-5, experience dental caries, and according to the 2000 Oral Health in America: A Report of the Surgeon General, up to 90% of all dental caries in children's teeth occur in pit and fissures.  With this information, it just makes sense that IHS dental providers should routinely be placing sealants on primary molars. If good moisture control and isolation can be maintained, then traditional resin-based sealant material is the ideal choice.  However, if we know that moisture control and isolation will be a problem due to behavior or another reason, then a glass ionomer sealant material is a good alternative. Glass ionomer sealants are advocated by the IHS Division of Oral Health when circumstances do not permit optimum isolation specifically partially erupted teeth and pre-cooperative patients.

37 Glass Ionomer Sealant Technique Steps
Examination and Diagnosis Explanation Preparation Isolation Conditioner Placement Fluoride varnish The technique for placing glass ionomer sealants is similar to ITRs because the same material is used. We have provided a copy of the sealant handout. We suggest downloading and printing it to be able to follow the step-by-step techniques.

38 Step 1: Examination and Diagnosis
We recline the child in a knee-to-knee position to examine the child’s teeth. At this time we can make a determination whether we will be placing a glass ionomer sealant or a resin sealant. The decision is based on the cooperation of the child and whether optimal moisture control can be attained and maintained.

39 Step 2: Explanation We show the parent or guardian what treatment we are going to provide and request their consent. We explain the purpose of sealants and why the child needs to come back to the clinic to have the sealants checked for retention and be recharged with fluoride varnish every three months. We are also emphasize that sealants can be done without local anesthetic.

40 Step 3: Preparation As with ITR, we need to prepare a tray set up for glass ionomer sealants. We need to have a mirror, cavity conditioner, autocure glass ionomer, fluoride varnish, micro applicator brush, and 2X2 gauze. Remember cavity conditioner is not the same material as the etchant used in resin sealants. Do not substitute!

41 Steps 4 and 5: Isolate and Condition
Isolate a quadrant by using folded 2x2 gauze squares. Apply conditioner with the micro brush. Remove excess conditioner and dry the occlusal surface.

42 Step 6: Placement The next step is to place the glass ionomer sealant and force the material into the grooves with moderate finger pressure. We may have remnants of the conditioner left on the occlusal surface. The conditioner (carboxylic acid) is a component of the glass ionomer material so it is not critical that the surface is meticulously rinsed, as is the case for resin sealants. This is the main reason why the manufacture recommends not using conventional etchant (phosphoric acid) when placing glass ionomer sealants.

43 Step 6: Placement Some dentists have found applying a very thin film of Vaseline with a small q-tip is effective in preventing over hydration of the glass ionomer sealant. This is not, however, required if we intend to apply fluoride varnish.

44 Step 6: Placement Remove excess material from the smooth surfaces and isolate the teeth for additional seconds. The last step is to apply fluoride varnish to all the teeth.

45 Glass-Ionomer Sealants
We accept the fact that the retention of a glass ionomer sealant is not equal to a resin sealant. By definition the placement of glass ionomer sealants is an acknowledgement of a compromised situation. Resin sealants are stronger and therefore, a resin sealant should be placed if a dry field can be maintained. Glass ionomer sealants are endorsed by AAPD and the IHS Division of Oral Health only when moisture control cannot be achieved and a resin sealant is not feasible. Placing G I sealants may have a pre-emptive benefit and may defer the necessity of traditional dental treatment until the child is older. We place GI sealants on children with high caries risk, and when inadequate isolation or poor cooperation is anticipated. We have not found any contraindications for placing GI sealants, aside from utterly defiant patient behavior. Also, keep in mind that it is almost always better to do something than to do nothing at all, because we know that dental caries, left untreated, will progress.

46 Factors for Success Sealant success can be measured by retention or by caries prevention. In one study, GI sealant retention was not as good as that of a traditional resin, but was equivalent in caries prevention. Factors for success depend on persistence and developing an organized routine. We have improved our isolation technique to include minimal use of the air/water syringe and high vacuum suction. Cotton isolation combined with very gentle “puffs of air” seems effective. We are persistent, but that does not mean we schedule and treat a 2 year old child until eight perfect sealants are completed. What seems to work is to place sealants on two quadrants during a 15 minute appointment. Then we schedule the child for another 15 minute sealant appointment to complete the other two quadrants, and add a fluoride varnish treatment. Most parents are aware of sealants and appreciate that we are trying to prevent their baby from getting cavities even if it means follow-up appointments to confirm the retention or re-seal the failures or provide fluoride varnish treatments.

47 Patient Management Tips
Here are some patient management tips that will be helpful when working with a young child. Use “show and tell” approach to let the child know what you will be doing. Distract young patients by giving them a plastic mouth mirror or toothbrush to play with. Call the pink ITRs “Barbie” or “Spiderman” fillings. This sets a different tone that is more friendly than clinical. Keep your cool! Always remain calm because if you are calm, the child, and the parent, will often remain calm.

48 Oral Health Messages Recharging ITR
Twice daily brushing with fluoride toothpaste Fluoride varnish every three months Goal setting to improve oral health When we provide caries stabilization we always provide education to the parent/caregiver. We reiterate that ITR and glass ionomer sealants are temporary, but may indeed last the life of a primary tooth. We stress the importance of recharging the restoration daily with fluoride toothpaste, and recommend follow-up visits to apply fluoride varnish every three months. We have found that using goal setting with parents is helpful to encourage parents to change behaviors to prevent caries. Using the goal setting form is also an easy way to remind parents never to put a baby to bed with a bottle and limit intake of sugary foods and drinks.

49 Coding Current Dental Terminology 2009-10, Page 147, #12
2940 for ITRs 1351 for resin or glass ionomer sealants. 1203 Fluoride varnish for child at low risk for caries 1206 Fluoride varnish for child at moderate to high risk for caries 1310 Nutritional counseling provided to child and caregiver 1330 Oral hygiene instructions provided to child and caregiver When coding, use 2940 for interim therapeutic restorations. A dental sealant is coded If the resin or glass ionomer is “limited to the enamel” it is considered to be a dental sealant (Code 1351). This means that even if there is decay but it is limited to the enamel, it is a dental sealant. Other codes that are used include: 1203 Fluoride varnish for child at low risk for caries 1206 Fluoride varnish for child at moderate to high risk for caries 1310 Nutritional counseling provided to child and caregiver 1330 Oral hygiene instructions provided to child and caregiver

50 Goals: Improve access for young children and increase options for treating ECC.
Working with young children may be challenging, and using caries stabilization may make it easier for you, your staff and your young patients. The goal of caries stabilization is to provide treatment to young children without using local anesthetic. We do this by using glass ionomer ITRs which consists of a material that releases fluoride, and reduces caries-causing bacteria within the oral environment. We also use resin and glass ionomer sealants to protect pit and fissures of posterior teeth, and apply fluoride varnish to recharge ITRs and sealants as well as to strengthen and protect all of the teeth. By incorporating caries stabilization in our practice we are able to improve access for young children and increase our options for treating ECC.

51 We hope YOU incorporate Caries Stabilization into your dental program!
We really do hope that you will incorporate Caries Stabilization into your dental program!

52 References American Academy of Pediatric Dentistry, Policy on Interim Therapeutic Restorations, Reference Manual V 31/No6 09/10. Chadwick BL, Treasure ET, Playle RA, Caries Res Jan-Feb;39(1): A randomised controlled trial to determine the effectiveness of glass ionomer sealants in pre-school children. Community Dentistry and Oral Epidemiology  Supplement , Proceedings: Conference on Early Childhood Caries, Ed: B. Burt Lindemeyer, R. JCDA. March 2007, Vol. 73, No. 2. The Use of Glass Ionomer Sealants on Newly Erupting Permanent Molars. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep caries lesions after incomplete dentine caries removal: 40-month follow-up study. Caries Res. 2007;41(6):493–496. Mejare I, Mior, IA. Scand J Dent Res Aug;98(4): Glass ionomer and resin-based fissure sealants: a clinical study. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev. 2006;3:CD Vij, Coll, Shelton, Farooq; Caries control and other variables associated with success of primary molar vital pulp therapy. Ped Dent 2004, 26: We would like to thank California First Smiles and to Dr. Rochelle Lindemeyer for use of their photographs. To learn more about caries stabilization, we recommended these references. 52


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