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Breast feeding and ECC

Kotlow LA. Breastfeeding: a cause for dental caries in children. J Dent Child.1977; 44:192 Breastfeeding and the risk of early childhood caries. White V. Evid Based Dent. 2008;9(3):86-8. Association between infant breastfeeding and early childhood caries in the United States. Iida H, Auinger P, Billings RJ, Weitzman M. Pediatrics. 2007 Oct;120(4):e944-52 Erickson PR, Mazhari E. Investigation of the role of human breast milk in caries development. Pediatr Dent. 1999;21:86


1. Breast milk has a pH of 7.2 2. Proven health benefits of breastfeeding 3. Lack of consistent evidence 4. Promote breastfeeding 5. Emphasize OH and reduce CHO consumption


6 week old healthy infant is referred to you for problems with sucking. Pediatrician is concerned and noted a short tongue. Your examination reveals ankyloglossia. What do you tell the parent and pediatrician? Is there any evidence to support treatment? Evidence based decision: There are no controlled prospective trials for surgical interventions in infants with ankyloglossia, therefore there no conclusive suggestions regarding the method of intervention. Also controversial is which type of tongue-tie needs to be surgically repaired and which can be left to observe How severe is the condition? Is the infant having problems latching on to the mothers breast? Is the infant gaining weight?

1. Cochrane Oral Health Groupnothing 2. ADA EBD: nothing 3. PubMed: Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Geddes DT, et al Pediatrics. 2008 Jul;122(1):e188- 94. 4.NGCH1. Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Academy of Breastfeeding Medicine Professional Association. 2004.

Pulp Therapy Mythology

Evidence for Pulpal Therapy

With rare exception, the studies we rely on are academic thesis projects Almost all use the same inclusion criteria which really dont reflect clinical reality Few follow their teeth through exfoliation and eruption of the succedaneous teeth Results are often clouded by purist views of radiologic success

Whats the Evidence for Pulp Therapy?

Nadin G, Goel BR, et al. Pulp treatment for extensive decay in primary teeth (Cochrane Review). The Cochrane Library 2003;2:1-30.
Searched all languages, found 138 references, read 77 in entirety, and Three studies met criteria for inclusion! Conclusion: Insufficient randomized trials to provide reliable evidence supporting one type of pulp treatment as superior to others

Common Clinical Situations

What Evidence Exists On Diagnosis of the Primary Pulp

Extent of Carious Lesions Tooth Coloration Location of Tooth Clinical, Radiographic and Bleeding

The Extent of Caries

The relationship between extent of carious involvement of the marginal ridge and pulp inflammation in primary molars MS Duggal, A Nooh, A High. J Dent Res Abs # 1540, 1999
Classified marginal ridge caries Pulp changes identified in 80% of teeth with <2/3rd of ridge involved Pulp changes in 100% of teeth with > 2/3rd of ridge involved Part of UK guidelines for pulp therapy

The Extent of Caries

Histopathology of the pulp in primary incisors with deep dentinal caries. Eidelman, E et al. Pediatric Dent 1992;14:372

Looked at 53 carious primary incisor pulps without x-ray or clinical pathosis, but deemed unrestorable Removed caries after these teeth extracted as one would do if they were to be saved Had carious exposures on 24 but not on 29 of these Of 29 unexposed, only 6 were histologically healthy pulps None of the 24 exposed pulps were histologically normal; two-thirds had coronal inflammation


Sonis et al. Longitudinal study of discolored primary teeth and effect on succedaneous teeth. J Pedo 1987;11:247 Followed 37 darkened incisors until lost and eruption of successor No clinical or x-ray pathosis on 72 percent Only 11 teeth with pathosis Only one successor had enamel problems; and successors tended to erupt early

Are Dark Teeth Sick Teeth?

Soxman JA et al. Pulpal pathology in relation to discoloration of primary anterior teeth. JDC 1984;51:282 Total necrosis in 11/23 and as early as 10 days S/P trauma No correlation between color and histopathological status


Who Wins the Technique War?

Study Yr 91 N Time (mos) 12 % Clin 96 % Xray 96

Fei et al Casas et al







Fuks et al






Smith et al







Pulpectomies Work as Well

Two-year outcomes of primary molar ferric sulfate pulpotomy and root canal therapy. Casas MJ et al. Pediatr Dent 2003;25:97 Studied 109 molar pulpectomies and they were as good as ferric sulfate pulpotomies (98% after 2 years) An evaluation of pulpal therapy in primary incisors. Coll JA et al. Pediatr Dent 1988;10:178. Studied 27 incisor pulpectomies and found them 78% effective after 45.5 months


Pulpectomy Research Support

Success rate of root canal treatment in primary molars. Moskovitz et al J Dent (2005): 41-47 Found 85% success rate with pulpectomy procedure
Filled with IRM

Ballesio et al Eur J Pediatr Dent (2002) 133-140. Chemical and pharmacological shaping of necrotic primary teeth. Found 92% success rate
Necrotic primary molars with fistulas First visit: canals filled with powdered antibiotic mixed with anesthetic solution Second visit: canals were filled with IRM

Who Has Time For This?

Coll J. Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date? Pediatr Dent 2008;30:230-236. This author recommends placement of GIC for several months in primary teeth when caries approaches the red zone While he maintains this is cheaper than a pulpotomy, he does not address cost of re-treatment which may be needed


Bring Back the Indirect Pulp Cap?

Indirect pulp treatment of primary posterior teeth: a retrospective study. Al-Zayer MA et al. Pediatr Dent 2003;25:29

Looked at 187 primary posterior teeth treated with indirect pulp therapy Deep dentinal caries, but no symptoms or x-ray signs of pulpal pathosis CaOH placed with crown, amalgam or composite A 95% success with a 96% 1-year success Crowns had best success


What Else About Pulp Therapy?

If we look at what the many studies tell us. Repeated studies suggest that regardless of medicament treatment success depends on initial pulp health [inclusion criterion for all studies] First primary molars uniformly have poorer prognosis compared to second molars Most studies show either little difference in success between clinical and x-ray findings, or use clinically irrelevant criteria, so dont radiograph without clinical signs Always follow pulp therapy with a crown


Why Do a 5-Minute Full Strength Histobiological effectiveness of a reduced FC Pulpotomy? concentration of Buckleys formocresol. Verco PJ.
Ped Dent 1985;7:130 Looked at S. faecalis, S. salivarius, Staph aureus Found formocresol concentrations of 0.05 to 0.33% to be bacteriocidal Comparison of antimicrobial and cytotoxic effects of glutaraldehyde and formocresol . Hill SD et al. O,O,O 1991;71:89 Mean microbicidal concentration of formocresol was 0.23% and cytotoxic concentration (fixation) was 0.0075% The minimum concentration of formocresol to kill 9 organisms was 0.75% for 2 minutes


Confused? Me Too!
Literature on FC, FS, MTA, laser, NaOCl, CH is often conflicting or does not track long enough to show a measurable difference to merit switching materials If what you use works, keep using it!


So What Does the Evidence Say?

Carious primary tooth with deep caries but no exposure, do an indirect pulp cap Carious primary tooth with stoppable pulpal hemorrhage and no other clinical or radiographic signs, do a pulpotomy Carious primary tooth with pulpal pathosis but good root structure (ie, no resorption) do a pulpectomy



Restorative Care


Stainless Steel Crowns: Underused, Abused and Misunderstood

Longevity of crowns compared to amalgam demonstrated clearly by numerous studies
Author Amalgams placed Failures #/(%) SSCs placed Failures #/% Study Duration

Braff 1975





2.5 yr

Dawson 1981
Messer 1988 Roberts 1990 Einwag 1996

1177 706 66

255(22) 82(12) 38(58)

331 673 66

40(12) 13(2) 4(6)

2 or more yr
5 yr 10 yr 8 yr

Stainless Steel Crowns: Not Much Evidence on Technique

Pre-crimped, precontoured crowns or do it yourself? Trimming crowns? One brand versus another? Polishing before cementation? Type of cement used? High occlusion?


SSC Types
3M (Ion) pre-crimped pre-contoured pre-trimmed pre-ferred!

Unitek not pre-crimped not pre-contoured not pre-trimmed

2nd molar

1st molar