This article addresses advances in 4 key areas related to pediatric dentistry: (1) caries detection tools, (2) early interventions to arrest disease progression, (3) caries-risk assessment tools, and (4) trends in pediatric procedures and dental materials.
The use of new technology is shifting the practice of dentistry. New imaging devices, restorative procedures, and the application of the Internet and powerful electronic devices are examples of advances that have made a foremost impact on dentistry. Even though pediatric dentists may not have as many new tools of treatments compared with dentistry colleagues, their practices have nonetheless been improved significantly in recent years by advancements. Newer-generation imaging devices have allowed us to view details of the dental anatomy that heretofore were not visible to us before. This article summarizes the current state of pediatric dentistry.
Caries detection diagnostic/imaging tools
Early detection is crucial in the management of dental caries. When detected at an early stage at which the enamel surface has not collapsed, the incipient lesion can be treated with preventative therapies that can retard and eventually arrest the progression of early lesions and preserve the enamel tooth structure, function, and aesthetics.
Traditionally, a subjective method of visual inspection has been used as the most ubiquitous caries detection method. Key features, such as color and texture, are assessed. The assessment indicates some information on the severity of the caries process but falls short of true quantification. In addition to its limited detection threshold, the ability of this assessment to detect early, noncavitated lesions is poor.
To meet the challenges in dentistry, there is a tremendous need for a range of caries detection and quantification systems to augment the practitioner’s diagnostic pathway. A range of relatively new detection systems, including diagnodent laser device (KaVo, Biberach, Germany), digital imaging fiber-optic transillumination (DIFOTI, KaVo Dental, Lake Zurich, IL, USA), and quantitative light-induced fluorescence (QLF, QLF-clin, Inspektor Research Systems BV, Amsterdam, Netherlands), are considered as possible supplemental techniques for detecting incipient carious lesions.
Diagnodent Laser Device
Many studies have demonstrated that the diagnodent device is a valuable addition to the clinical examination and appropriate also for longitudinal monitoring of the occlusal and smooth surface caries process because of its objective readings.
The device emits fluorescence after application of pulsed red light with a wavelength of 655 nm, and the fluorescence emitted from the tooth is translated into a numerical scale from 0 to 99. When irradiated by light of a given wavelength, the tooth surface fluoresces. The laser light is absorbed by organic and inorganic substances present in the dental tissues and also by metabolites from oral bacteria. It is these metabolites that result in the red fluorescence of carious dentin. There is a baseline fluorescence level for sound enamel and a different fluorescence level after the caries process has initiated. It has been shown that deeper and hence more demineralized lesions have a higher fluorescence reading at the surface of the tooth. Nonetheless, whether this increased reading corresponds to an increased bacterial load within the lesion has yet to be demonstrated.
DIFOTI
Different diagnostic tools, including digital bitewing radiographs, fiber-optic transillumination (FOTI), and DIFOTI, are used for a more accurate and reliable diagnosis for interproximal carious lesions. The basic principle behind transillumination is that demineralized areas of enamel or dentin scatter light more than sound areas of enamel and dentin.
The system of FOTI is made of a high intensity light and a gray scale camera that can be fitted with 1 of 2 heads; one for smooth surfaces and one for occlusal surfaces. Images can then be displayed on a computer monitor and be archived for later examination. However, quantification of the images is not possible, and hence the analysis is to be undertaken in conjunction with a visual examination by the clinician who has to decide subjectively based on the appearance of scattering. Because there are no continuous data outputted, longitudinal monitoring is not possible. Therefore, some degree of training is recommended to be competent at this level of FOTI use.
Digital imaging is a more recent development combining FOTI with a charge-coupled digital intraoral camera. This technology involves light, a charge-coupled device camera, and a computer-controlled image acquisition. Digital imaging’s advantages over traditional radiography include the absence of ionizing radiation, the lack of a need for film, real-time diagnosis, and higher sensitivity in detection of early lesions that are not apparent in radiography.
QLF
QLF is a visible light system that offers an opportunity for early detection of caries and also its longitudinal monitoring. With 2 forms of fluorescent detection, green and red, QLF can determine if a lesion is active or not and can document the progression of any given lesion. Here, the visible light has a wavelength of 370 nm, which is in the blue region of the spectrum. The resultant autofluorescence of human enamel is then detected by filtering out the excitation light using a bandpass filter at a wavelength greater than 540 nm via a small intraoral camera, which produces an image of only green and red channels because blue light has been filtered out. The color of the enamel is green and the demineralization of enamel results in a reduction of this autofluorescence. The loss can then be quantified with proprietary software.
Live images are displayed via a computer, and the accompanying software enables the patient’s details to be entered and the individual images of the teeth of interest to be captured and stored. The captured images can be analyzed to quantitatively assess demineralization. The images can be stored and transmitted for referral purposes if needed. The images could also be used as patient motivators as well. This device is one of the most promising technologies in the caries detection presently despite the fact that further research is required to demonstrate its ability to correctly monitor lesion changes over time.
Optical Coherence Tomography
There are several other techniques for detecting caries using optical methods. Systems such as optical coherence tomography (OCT) and near-infrared imaging OCT are in their infancy but may prove useful in the future. There is significant work involved in developing these systems into clinically and commercially acceptable applications, and so, it may be some time until these new methodologies can be properly assessed in clinical trials.
Early interventions to prevent diseases progression
Although dental disease is preventable, its effect ranges from a minor inconvenience requiring restorative treatment to discomfort and loss of function. The role of bacterial plaque in caries causation is clear, yet strategies at eliminating specific microorganisms have proven to be difficult. The benefits of the use of topical antimicrobials and the use of topical fluorides in a wide array of formulations and methods of delivery are accepted by the pediatric scientific and practicing community. Remineralization strategies other than fluoride as well as the use of high-concentration fluoride preparations intended to slow the dental caries process are addressed.
Antiseptics
A topical antiseptic prevents or arrests the growth or action of microorganisms when applied to living tissues. Antiseptics have a considerably broader spectrum of activity than antibiotics. Unlike antibiotics, antiseptics have multiple intracellular targets that reduce the likelihood of resistance development. However, antiseptics application should be limited to infected wounds, skin, and mucosa. There are studies on the utility of antiseptic agents to slow progression of caries in older self-compliant patients. Some clinicians are advocates of combining antimicrobials and topical fluorides to provide more comprehensive protection against the caries progression process in young children.
Chlorhexidine Digluconate
Chlorhexidine (CHX) rinses are biguanide antimicrobials with broad-spectrum antimicrobial properties that have been used as a first defense in treating dental caries. At present, several CHX rinses are available commercially that differ in formulation, and the regimen of use is United States Food and Drug Administration (FDA) approved for gingivitis control. The 0.12% and 0.2% commercial formulations when rinsed according to the respective manufacturer’s instructions produced similar large and prolonged reductions in salivary bacterial counts. At present, no formulation has the FDA approval for caries control in children. Besides the antiplaque and antigingivitis activities, the formulation is also effective in the prevention of infectious complications of oral origin.
Research on the effectiveness of a CHX varnish coating has shown mixed results. A systematic review of 14 publications of controlled clinical trials concluded that there was a moderate caries-reducing effect when the varnish was applied every 3 months. At present, the evidence is inconclusive regarding CHX varnishes and CHX-containing vehicles; no products for children are available in the United States. Although CHX is being considered as the gold standard for antiplaque and antigingivitis agents, it is noted that the side effects of CHX include staining of teeth and poor taste.
Povidone-Iodine
Iodine has been used for more than 150 years in mucosal antisepsis, therapies for skin infections and burns, and wound management. As povidone-iodine (PI) was introduced in the 1960s, it was possible to use this highly efficient microbicide for bacterial, fungal, and viral infections.
Intraorally, short durations of PI contact with various periodontopathic bacteria are effective in in vitro killing and exhibit marked anticytomegaloviral activity. PI is water soluble and hence does not irritate healthy oral mucosa. PI does not show adverse side effects, such as discoloration of teeth and tongue and change in taste sensation as noted with CHX. Small-scale studies of PI utility in young children, some with established active early childhood caries, demonstrate promising data. Contraindications are patients with iodine hypersensitivity and thyroid pathosis, as well as pregnant and nursing women for protection of the infant ; however, more studies need to be followed.
Topical Fluorides
Professionally applied topical fluorides are used restrictively in dental offices and may be supplied in solutions, gels, varnishes, foams, or prophylactic pastes. Fluoride can be applied using different methods: 1100-ppm fluoride dentifrice, 5000-ppm fluoride gels and foams, 223-ppm fluoride rinse, and 23,000-ppm fluoride varnish. Fluoride’s basic mode of action, which is well established, is to enhance remineralization and simultaneously inhibit demineralization. Fluoride ions are incorporated into remineralizing enamel/dentin, changing carbonated apatite to a fluorapatitelike form that is more acid tolerant and makes the hard tissues more acid resistant. Further, fluoride inhibits bacterial intracellular enzymes.
Fluoride varnish
Sodium fluoride varnishes are being used for caries arrest in children, and data suggest that these using this varnish is more effective that older technologies. Varnishes are safe for at-risk infants and toddlers and provide an easy-to-use fluoride vehicle for young children. Although varnishes are being adopted in public health dental-medical settings, its use in private dental settings lags.
Silver diamine fluoride
Historically, silver has been used in water purification, wound care, bone prostheses, reconstructive orthopedic surgery, cardiac devices, catheters, and surgical appliances. Advancing biotechnology has enabled incorporation of ionizable silver into fabrics for clinical use to reduce the risk of nosocomial infections and for personal hygiene.
Silver diamine fluorides (SDFs) can be used to halt the cariogenic process and further prevent new caries with silver salt–stimulated sclerotic or calcified dentin formation, silver nitrate’s potent germicidal effect, and fluoride’s ability to reduce decay. The antimicrobial action of silver compounds is proportional to the bioactive silver ion released and the availability of the ion to interact with bacterial or fungal cell membranes. The specific interest in SDF centers around its presumed attributes : control of pain and infection, ease and simplicity of use (paint on), affordability of material, minimal requirement for personnel time and training, and noninvasiveness. The side effects of SDF include teeth staining and unpleasant poor taste.
A 38% (44,800-ppm fluoride ions) SDF solution is commonly used to arrest caries in primary teeth, especially of those children who are young and less cooperative. In these cases, SDF allows definitive restoration to be performed when these children grow older and become more receptive to dental procedures. Research has demonstrated the value of SDF to both arrest and prevent caries recurrence. Current evidence suggests that SDF is 2 times as effective as sodium fluoride varnish ; however, further research is needed to learn how the compound works.
Calcium phosphate fluoride
There are developing, interesting, and novel remineralizing agents, such as casein phosphopeptide–amorphous calcium phosphate, formulated as professionally applied pastes and toothpastes. Two studies have demonstrated increased incorporation of fluoride ions into the enamel subsurface to promote remineralization of incipient lesions. More studies on early control of dental caries in young children are needed. These remineralizing agents may complement and increase the established clinical effectiveness of topical fluorides.
Xylitol
Xylitol is a naturally occurring alcohol sugar that is not metabolized by Streptococcus mutans (mutans streptococci [MS]). Xylitol inhibits the attachment of the biofilm and interferes with intracellular metabolism. Xylitol is available in many forms: gum, lozenges, mints, sprays, rinses, pastes, and a baking substitute for sugar or other sweeteners. Studies indicate that a dose of 6 g to 10 g per day significantly reduces levels of MS. Patients should also be cautioned that xylitol can create gastrointestinal distress at high levels of consumption. The American Academy of Pediatric Dentistry (AAPD) supports the use of xylitol chewing gum as a caries inhibitor but recommends further research. Two key studies demonstrated that when mothers of very young children chewed high-content xylitol gum, their children had delayed colonization and lower levels of MS and reduced caries experience.
Sealants
Among school-aged children, most dental caries has been detected on pit and fissure surfaces of their first and second molars. Occlusal sealants were introduced in the 1960s for protecting pits and fissures from dental caries. At present, there are 2 main types of sealant materials available: resin-based sealants and glass ionomer cements. The resin-based sealants are divided into generations according to their mechanism for polymerization or their content. The development of sealants has progressed from first-generation sealants (no longer available) to second- and third-generation sealants, which are autopolymerized and visible light activated, and finally to fourth-generation sealants containing fluoride. The effectiveness of resin-based sealants has been shown, and the effectiveness depends on the longevity of sealant coverage. The second main type of sealant material is glass ionomer cements that were introduced in 1974. The results of studies using glass ionomer sealants have thus far been conflicting. The main disadvantage of glass ionomer sealant has been inadequate retention. Nevertheless, it has been suggested that glass ionomer sealants, through their fluoride release, can prevent the development of caries even after the visible loss of sealant material.
Early interventions to prevent diseases progression
Although dental disease is preventable, its effect ranges from a minor inconvenience requiring restorative treatment to discomfort and loss of function. The role of bacterial plaque in caries causation is clear, yet strategies at eliminating specific microorganisms have proven to be difficult. The benefits of the use of topical antimicrobials and the use of topical fluorides in a wide array of formulations and methods of delivery are accepted by the pediatric scientific and practicing community. Remineralization strategies other than fluoride as well as the use of high-concentration fluoride preparations intended to slow the dental caries process are addressed.
Antiseptics
A topical antiseptic prevents or arrests the growth or action of microorganisms when applied to living tissues. Antiseptics have a considerably broader spectrum of activity than antibiotics. Unlike antibiotics, antiseptics have multiple intracellular targets that reduce the likelihood of resistance development. However, antiseptics application should be limited to infected wounds, skin, and mucosa. There are studies on the utility of antiseptic agents to slow progression of caries in older self-compliant patients. Some clinicians are advocates of combining antimicrobials and topical fluorides to provide more comprehensive protection against the caries progression process in young children.
Chlorhexidine Digluconate
Chlorhexidine (CHX) rinses are biguanide antimicrobials with broad-spectrum antimicrobial properties that have been used as a first defense in treating dental caries. At present, several CHX rinses are available commercially that differ in formulation, and the regimen of use is United States Food and Drug Administration (FDA) approved for gingivitis control. The 0.12% and 0.2% commercial formulations when rinsed according to the respective manufacturer’s instructions produced similar large and prolonged reductions in salivary bacterial counts. At present, no formulation has the FDA approval for caries control in children. Besides the antiplaque and antigingivitis activities, the formulation is also effective in the prevention of infectious complications of oral origin.
Research on the effectiveness of a CHX varnish coating has shown mixed results. A systematic review of 14 publications of controlled clinical trials concluded that there was a moderate caries-reducing effect when the varnish was applied every 3 months. At present, the evidence is inconclusive regarding CHX varnishes and CHX-containing vehicles; no products for children are available in the United States. Although CHX is being considered as the gold standard for antiplaque and antigingivitis agents, it is noted that the side effects of CHX include staining of teeth and poor taste.
Povidone-Iodine
Iodine has been used for more than 150 years in mucosal antisepsis, therapies for skin infections and burns, and wound management. As povidone-iodine (PI) was introduced in the 1960s, it was possible to use this highly efficient microbicide for bacterial, fungal, and viral infections.
Intraorally, short durations of PI contact with various periodontopathic bacteria are effective in in vitro killing and exhibit marked anticytomegaloviral activity. PI is water soluble and hence does not irritate healthy oral mucosa. PI does not show adverse side effects, such as discoloration of teeth and tongue and change in taste sensation as noted with CHX. Small-scale studies of PI utility in young children, some with established active early childhood caries, demonstrate promising data. Contraindications are patients with iodine hypersensitivity and thyroid pathosis, as well as pregnant and nursing women for protection of the infant ; however, more studies need to be followed.
Topical Fluorides
Professionally applied topical fluorides are used restrictively in dental offices and may be supplied in solutions, gels, varnishes, foams, or prophylactic pastes. Fluoride can be applied using different methods: 1100-ppm fluoride dentifrice, 5000-ppm fluoride gels and foams, 223-ppm fluoride rinse, and 23,000-ppm fluoride varnish. Fluoride’s basic mode of action, which is well established, is to enhance remineralization and simultaneously inhibit demineralization. Fluoride ions are incorporated into remineralizing enamel/dentin, changing carbonated apatite to a fluorapatitelike form that is more acid tolerant and makes the hard tissues more acid resistant. Further, fluoride inhibits bacterial intracellular enzymes.
Fluoride varnish
Sodium fluoride varnishes are being used for caries arrest in children, and data suggest that these using this varnish is more effective that older technologies. Varnishes are safe for at-risk infants and toddlers and provide an easy-to-use fluoride vehicle for young children. Although varnishes are being adopted in public health dental-medical settings, its use in private dental settings lags.
Silver diamine fluoride
Historically, silver has been used in water purification, wound care, bone prostheses, reconstructive orthopedic surgery, cardiac devices, catheters, and surgical appliances. Advancing biotechnology has enabled incorporation of ionizable silver into fabrics for clinical use to reduce the risk of nosocomial infections and for personal hygiene.
Silver diamine fluorides (SDFs) can be used to halt the cariogenic process and further prevent new caries with silver salt–stimulated sclerotic or calcified dentin formation, silver nitrate’s potent germicidal effect, and fluoride’s ability to reduce decay. The antimicrobial action of silver compounds is proportional to the bioactive silver ion released and the availability of the ion to interact with bacterial or fungal cell membranes. The specific interest in SDF centers around its presumed attributes : control of pain and infection, ease and simplicity of use (paint on), affordability of material, minimal requirement for personnel time and training, and noninvasiveness. The side effects of SDF include teeth staining and unpleasant poor taste.
A 38% (44,800-ppm fluoride ions) SDF solution is commonly used to arrest caries in primary teeth, especially of those children who are young and less cooperative. In these cases, SDF allows definitive restoration to be performed when these children grow older and become more receptive to dental procedures. Research has demonstrated the value of SDF to both arrest and prevent caries recurrence. Current evidence suggests that SDF is 2 times as effective as sodium fluoride varnish ; however, further research is needed to learn how the compound works.
Calcium phosphate fluoride
There are developing, interesting, and novel remineralizing agents, such as casein phosphopeptide–amorphous calcium phosphate, formulated as professionally applied pastes and toothpastes. Two studies have demonstrated increased incorporation of fluoride ions into the enamel subsurface to promote remineralization of incipient lesions. More studies on early control of dental caries in young children are needed. These remineralizing agents may complement and increase the established clinical effectiveness of topical fluorides.
Xylitol
Xylitol is a naturally occurring alcohol sugar that is not metabolized by Streptococcus mutans (mutans streptococci [MS]). Xylitol inhibits the attachment of the biofilm and interferes with intracellular metabolism. Xylitol is available in many forms: gum, lozenges, mints, sprays, rinses, pastes, and a baking substitute for sugar or other sweeteners. Studies indicate that a dose of 6 g to 10 g per day significantly reduces levels of MS. Patients should also be cautioned that xylitol can create gastrointestinal distress at high levels of consumption. The American Academy of Pediatric Dentistry (AAPD) supports the use of xylitol chewing gum as a caries inhibitor but recommends further research. Two key studies demonstrated that when mothers of very young children chewed high-content xylitol gum, their children had delayed colonization and lower levels of MS and reduced caries experience.
Sealants
Among school-aged children, most dental caries has been detected on pit and fissure surfaces of their first and second molars. Occlusal sealants were introduced in the 1960s for protecting pits and fissures from dental caries. At present, there are 2 main types of sealant materials available: resin-based sealants and glass ionomer cements. The resin-based sealants are divided into generations according to their mechanism for polymerization or their content. The development of sealants has progressed from first-generation sealants (no longer available) to second- and third-generation sealants, which are autopolymerized and visible light activated, and finally to fourth-generation sealants containing fluoride. The effectiveness of resin-based sealants has been shown, and the effectiveness depends on the longevity of sealant coverage. The second main type of sealant material is glass ionomer cements that were introduced in 1974. The results of studies using glass ionomer sealants have thus far been conflicting. The main disadvantage of glass ionomer sealant has been inadequate retention. Nevertheless, it has been suggested that glass ionomer sealants, through their fluoride release, can prevent the development of caries even after the visible loss of sealant material.
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