Intriguing options for kids: Pediatric dentistry offers innovative options for treatment

By Cathy Hester Seckman, RDH

Pediatric specialization has been a recognized part of dentistry since at least 1901, when Dr. M. Evangeline Jordon developed a lecture titled "Care of Children's Teeth." In 1909, she began limiting her California dental practice to children, and in 1924, she published a pediatric dentistry text. She was also one of the founders of the American Society of Dentistry for Children.¹

The American Academy of Pediatric Dentistry (AAPD), founded in 1947, has furthered Dr. Jordon's work and developed the specialty we know today as pediatric dentistry. Researchers are studying emerging trends and new equipment as they apply to treating children. The following include some of the most intriguing options.

Caries-risk assessment

Caries-risk assessment tools (CAT), which seek to quantify risk, have been found to work well with preschool children, but have limited accuracy in older children and adolescents. Baseline caries, researchers stated, was the most accurate predictor for all age groups.² At the simplest level, in other words, if a child has had caries, he or she is likely to develop caries again.

The AAPD offers guidelines for using CAT with children. The tools, says the AAPD, should not involve disease outcome but disease treatment, either anticipating or stabilizing caries. They should provide an understanding of the disease process in specific patients and aid the clinician in patient/parent discussions.

Factors involved in risk assessment include "the likelihood of the incidence of caries during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present."³ Models used employ different combinations of factors to quantify risk, including these:

• Susceptibility of host
• Diet
• Nighttime bottle use
• Plaque accumulation
• Mutans Streptococci levels
• Other microflora present
• Exposure to fluoride
• Social factors
• Cultural factors
• Behavioral factors

To offer children the best outcome from caries risk assessment tools, the assessment should be completed as early as possible and before disease occurs.⁴ A caries risk assessment can be completed by a hygienist, giving both hygienist and dentist an opportunity to stop caries before it gets a good start.

Caries detection tools

The most interesting result of caries-detection technology has been our ability to apply early intervention strategies to stop caries in its tracks before it fully develops. In the past, we've depended on radiography, probing, and direct observation to detect caries, but these only find lesions that are already established. In addition, they can be subjective. We've all seen caries that we thought needed to be treated, only to have our employer decide to "watch" it.

There are now more objective (and more expensive) technologies available for caries detection, including light-induced fluorescence, laser-induced fluorescence, fiber-optic transillumination, and tomography. These technologies detect the earliest physical changes in a tooth when caries invades. Calcium, phosphate, and carbonate are lost, demineralizing enamel structure and leaving a porous structure vulnerable to bacteria. The structural change, visible as a white spot, can be measured and quantified with technology at a very early stage.⁵

Both the KaVo DIAGNOdent and the Canary Dental Caries Detection system use laser-induced fluorescence. The Midwest Caries I.D. and the Air Techniques Spectra use LED technology to detect caries signatures. A newer system, the Lantis Laser Optical Coherence Tomography (OCT) Dental Imaging System, promises to image teeth and supporting structures with a hand-held scanner.⁶

Regulations on the use of such tools by hygienists vary from state to state.

Laser therapy

Picture this scenario. You've taken your own child to the pediatric dentist, who has found a small occlusal on a primary second molar. "Why don't we just take care of that right now," the dentist says after the exam. "I'll set up the laser." Your child could have the decay treated immediately, with no anesthesia and no drilling. It's an attractive idea for any parent as well as for any child.

Laser ablation of decay has been used in dentistry since the early 1990s, but not often on primary teeth. That may be changing. A 2014 study in France using the Er:YAG laser demonstrated good acceptance by children when lower energy settings-perfect for primary enamel and dentin-were used.⁷ According to the American Academy of Pediatric Dentistry, erbium lasers are the most commonly used for hard-tissue procedures in children.⁸

Carbon dioxide lasers can be used on hard tissues as well. Inside Science, a web publication of the American Institute of Physics, reported last year that carbon-dioxide lasers, recently FDA-approved for dentistry, produce a numbing effect so most patients need no anesthetic.

CO₂ lasers have also produced positive results when irradiating enamel around orthodontic brackets. One study found higher enamel surface microhardness around brackets, and concluded that high-risk patients could benefit from laser treatment before orthodontic treatment.⁹

Think what that means to any hygienist. Picture the worst, most intractable brusher in your practice who is about to begin orthodontics. Doesn't the very idea give you nightmares? If that patient could avoid rows of half-moon decay just by having a laser treatment first, you'd breathe a lot easier, wouldn't you?

Though the technology is expensive, these and other types of lasers are becoming more common, even in pediatrics. The Journal of Lasers in Medical Sciences stated in a June 2015 article that children tolerate minimally invasive laser procedures well, and, as a consequence, so do their parents. According to the article, lasers can be used for caries detection, prevention, sealant preparation, restoration, pulpotomy, and pulpectomy. They are also used for soft-tissue procedures including hyperplasia reduction, aphthous and herpes lesions, and frenectomies. Yet more applications include vitality testing, preservation of pulp vitality, and raising patients' pain thresholds.¹⁰

A study done in Syria in 2008 even offered hope for lasers to shorten orthodontic time. Sixteen patients between the ages of 14 and 23 were treated with a low-level diode laser at zero-, three-, seven-, and 14-day intervals while canines were retracted. In a patient questionnaire, the subjects reported lower levels of pain than the control group. In addition, canine movement was significantly greater in patients treated with a laser.¹¹

Regulations on the use of lasers by hygienists vary from state to state.

Trends in procedures

Most of us are at least familiar with the concept of atraumatic restorative treatment (ART), which is popular in the mission field and for street dentistry. ART involves scooping out carious lesions with hand instruments, then using a glass ionomer composite to fill the opening and seal off decay from its oxygen and bacteria supply. It is beginning to be popular in pediatrics as well. Two studies found ART to be a good option for pediatric dentistry, especially for primary molars, with high survival rates for the restorations.^12,13

The Hall technique, named for Scottish dentist Dr. Norma Hall, is similar in philosophy to ART in that it isolates decay without removing it. In contrast, though, the Hall technique blocks existing decay with stainless steel crowns. The technique is only appropriate for teeth that have no pulpal involvement. First, orthodontic separators are placed to create interproximal space. After three to five days, separators are removed. The correct-size crown is chosen, using adhesive tape to temporarily stick the crown to the operator's finger for safety. The crown is then fitted on the tooth with self-curing glass ionomer cement.

The first random-controlled trials on the Hall technique were done in 2007, and reported a success rate of 98%. In the conventionally treated control restorations, the success rate was 85%.¹⁴ A follow-up study published this past October by the same researchers concluded the Hall technique continues to deliver more successful results than conventional treatment over the lifetime of the primary teeth.¹⁵

Regulations on the performance of ART and the Hall technique by hygienists and other auxiliaries vary from state to state.

What do these new options mean for pediatric dentistry? Many children in a pediatric practice are there because they've been management problems in general practice. They arrive with memories of a bad experience, reluctant, obstinate, frightened, or even terrified. These new options for treatment will give offices the ability to treat children without anesthesia, rubber dams, or drilling. And that makes the child, the parent, and the staff much calmer, and much, much happier. RDH

Cathy Hester Seckman, RDH, worked in dentistry 32 years, including 12 years as a pediatric hygienist. Officially retired from clinical hygiene, she still fills in occasionally at the same pediatric practice. She is a frequent contributor to dental magazines, works part-time as an indexer, and is the author of two novels, more than a dozen short stories, and an Arcadia Publishing history of her hometown.

References

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3. Guideline on Caries-risk Assessment and Management for Infants, Children, and Adolescents. Council on Clinical Affairs. American Academy of Pediatric Dentistry. Adopted 2002; Revised 2006, 2010, 2011, 2013, 2014.
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6. http://www.octnews.org/topic/profile/lantis-laser/. Accessed 11-12-15.
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11. Youssef M, Ashkar S, et al. The effect of low-level laser therapy during orthodontic movement: a preliminary study. Lasers Med Sci. 2008;23(1):27-33.
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13. Faccin ES, Ferreira SH, et al. Clinical performance of ART restorations in primary teeth: a survival analysis. J Clin Pediatr Dent. 2009;33(4):295-298.
14. Hussein, I. The Hall Technique: The novel method in restoring the carious primary molar that is challenging old concepts. A new tool in the general dentist's toolbox? Dental Tribune. 1-7-15. Accessed 11-12.15.
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