Prevention of Dental Disease

39 

Prevention of Dental Disease TAD R. MABRY

CHAPTER OUTLINE Risk Assessment Dietary Management Home Care Fluoride Administration Approach to the Adolescent Patient Caries Activity During Adolescence High-Frequency/Low-Concentration Applications Highly Concentrated Fluoride Agents Risk Factors Intraoral and Perioral Piercings Adolescent Pregnancy Smoking and Smokeless Tobacco Transitioning to Adulthood

A

dolescence generally denotes the period between childhood and adulthood. It is known for being a phase of life associated with change, rebellion, and friction. It encompasses a time frame when patients may progress from junior high school to senior high school and then go off to college, the workforce, or some other aspect of adult life. Adolescence can be a period of heightened involvement in peer group relationships, often at the expense of social or familial associations. The period encompasses the completion of physical growth and development in both girls and boys. Typically, all permanent teeth have erupted except for impacted third molars. The occlusion has stabilized either on its own or with orthodontic intervention. A gradual but continuous increase in the incidence of dental caries is often noted during this period.1 Periodontal disease may manifest itself because of fewer routine or parentally supervised home care sessions. The frequency of dental visits may decline. In addition, the increase in sex hormones in this age group is suspected to alter the subgingival microflora, resulting in an increased incidence of periodontal disease.2 Dietary habits undergo dramatic changes during this period. As adolescent girls complete their maximal growth and development, it is not unusual for them to begin dietary experimentation and modification. Some of these modifications can lead to serious pathologic conditions such as anorexia nervosa and bulimia. In adolescent boys, similar modifications in dietary habits occur. During this period the boy’s skeletal growth and body weight usually undergo dramatic changes, typically peaking at 16 to 18 588

years of age. Caloric requirements increase dramatically, and large amounts of protein and carbohydrates are consumed. In both boys and girls, irregular meals, frequent snacking, vending machine purchases, fast food meals, and unusual eating patterns are common practices. These changes can have profound effects on the oral environment and pose substantial challenges for the provision of professional dental care. The eruption of teeth into an environment of increased plaque secondary to reduced cleansing efforts combined with frequent snacking on foods and beverages high in carbohydrates can pose a significant risk for caries development in the immature enamel of newly erupted teeth. Besides being a time of increased caries risk, adolescence is also a time when the desire for social acceptance can lead individuals to actions that place them at risk for additional dental complications. Such actions would include tobacco and e-cigarette use, intraoral and perioral piercings, and adolescent pregnancy. Periodic professional visits that emphasize routine home care, optimal use of topical fluorides, dietary management strategies, and counseling on the dental implications of risky behaviors are both the goals and challenges for dentists who treat adolescents.

Risk Assessment Risk assessment takes on some added dimensions for the adolescent patient. Through the years, these individuals have become increasingly responsible for their own oral hygiene practices. Typically, it is the first time in their lives that they have a say in the decisionmaking process associated with their dental treatment options. Although treatment decisions are legally still in the hands of the parents or legal guardians, the wills and desires of the adolescent patient should not be discounted by the provider. The American Academy of Pediatric Dentistry (AAPD) has developed a set of guidelines used to assess the caries risk of patients in the mixed or permanent dentition (Table 39.1). In addition, the AAPD has developed caries management protocols based on these risk assessments (Table 39.2). Although these protocols are useful in determining the direction of patient care, they should be considered as guidelines only, and each adolescent should have an individualized treatment plan that addresses his or her unique preventive, restorative, and counseling needs. The caries risk assessment comprises just one part of the overall risk assessment for the adolescent patient. Other factors that must be considered when developing a comprehensive treatment plan include the need for, as well as the timing of, referrals for orthodontics or third molar extractions, where indicated. Risk factors such as pathologic dietary conditions, tobacco use, alcohol or drug

CHAPTER 39  Prevention of Dental Disease



589

TABLE Caries Risk Assessment for Patients Older Than 39.1  6 Years (for Dental Providers)

Factors

High Risk

Moderate Risk

Protective

Biologic Patient is of low socioeconomic status

Yes

Patient has >3 between meal sugar-containing snacks or beverages per day

Yes

Patient has special health care needs

Yes

Patient is a recent immigrant

Yes

Protective Patient receives optimally fluoridated drinking water

Yes

Patient brushes teeth daily with fluoridated toothpaste

Yes

Patient receives topical fluoride from health professional

Yes

Additional home measures (e.g., xylitol, MI Paste, antimicrobial)

Yes

Patient has dental home/regular dental care

Yes

Clinical Findings Patient has ≥1 interproximal lesions

Yes

Patient has active white spot lesions or enamel defects

Yes

Patient has low salivary flow

Yes

Patient has defective restorations

Yes

Patient wears an intraoral appliance

Yes

Circling those conditions that apply to a specific patient helps the practitioner and patient/ parent to understand the factors that contribute to or protect against caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (e.g., >1 interproximal lesion, low salivary flow) in determining overall risk. Overall assessment of the dental caries risk: Low □ Moderate □ High □ From American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(Special issue):142–149.

abuse, intraoral or perioral piercings, or teenage pregnancy must be factored in when planning treatment care for the adolescent. Counseling that addresses the dental as well as the medical complications associated with these risk factors should be included as part of the comprehensive treatment plan. If a provider is not comfortable or feels that further counseling expertise is warranted, a referral should be made to a professional who could provide such counseling. Anticipatory guidance is the implementation of preventive strategies based on a risk assessment. It is in the patient’s best interest to preemptively provide education that might prevent the development of a pathologic condition rather than treat the condition after it has occurred. For the infant or toddler a caries risk

• Figure 39.1

 

Brochures useful for guiding discussions with at-risk

adolescents.

assessment will typically dictate the focus of education to minimize the odds of development of early childhood caries. For the adolescent patient, anticipatory guidance not only includes caries reduction strategies based on a caries risk assessment but also preventive measures aimed at reducing the likelihood these individuals would choose to participate in behaviors that could jeopardize their oral health. Adolescents often participate in these types of activities without knowing the negative consequences associated with them. The goal of this form of anticipatory guidance is to educate adolescents on the detrimental effects associated with these risky behaviors in hopes that they may elect not to participate in these activities when pressured by their peers. Several organizations such as the AAPD, as well as the American Academy of Pediatrics (AAP) and the American Dental Association (ADA), have educational materials in the form of pamphlets and brochures that can be used to guide the discussion that a dental professional may have with the at-risk adolescent (Fig. 39.1).

Dietary Management As with younger age groups, the overall recommendations on dietary management for adolescents should concentrate on balanced intake, reduction of the frequency of snacking, and selection of foods that are not retentive to the teeth and soft tissues. Unfortunately, these recommendations conflict with the typical lifestyles of adolescents. With their newly gained independence, rebellious attitude toward established social systems, and acceptance of media messages and peer group pressure, it is a difficult task for the dentist and his or her staff to communicate recommendations and instill healthpromoting behaviors. Fortunately, owing to the increasing social development that occurs in middle adolescence, there is a strong desire to look attractive. The mouth takes on added importance. The challenge to dental professionals is to somehow make the daily care of teeth, including sound dietary habits, desirable for this patient population. For the patient who has been at high risk for dental disease during the early years and has had caries in the primary or mixed dentition, dietary management is a major concern. Depending on the patient’s present oral status, emotional and psychological maturity, and parental influences, counseling can be performed

590

Pa rt 5

Adolescence

TABLE 39.2  Example of a Caries Management Protocol for Patients Older Than 6 Years INTERVENTIONS

Risk Category

Diagnostics

Fluoride

Diet

Sealantsa

Restorative

Low risk

• Recall every 6–12 months • Radiographs every 12–24 months

• Twice daily brushing with fluoridated toothpasteb

No

Yes

• Surveillancec

Moderate-risk Patient/parent engaged

• Recall every 6 months • Radiographs every 6–12 months

• Twice daily brushing with fluoridated toothpasteb • Fluoride supplementsd • Professional topical treatment every 6 months

• Counseling

Yes

• Active surveillancee of incipient lesions • Restoration of cavitated or enlarging lesions

Moderate-risk Patient/parent not engaged

• Recall every 6 months • Radiographs every 6–12 months

• Twice daily brushing with toothpasteb • Professional topical treatment every 6 months

• Counseling, with limited expectations

Yes

• Active surveillancee of incipient lesions • Restoration of cavitated or enlarging lesions

High-risk patient/ parent engaged

• Recall every 3 months • Radiographs every 6 months

• Brushing with 0.5% fluoride • Fluoride supplementsd • Professional topical treatment every 3 months

• Counseling • Xylitol

Yes

• Active surveillancee of incipient lesions • Restoration of cavitated or enlarging lesions

High-risk Patient/parent not engaged

• Recall every 3 months • Radiographs every 6 months

• Brushing with 0.5% fluoride • Professional topical treatment every 3 months

• Counseling, with limited expectations • Xylitol

Yes

• Restore incipient, cavitated, or enlarging lesions

a

Indicated for teeth with deep fissure anatomy or developmental defects. Less concern about the quantity of toothpaste. c Periodic monitoring for signs of caries progression. d Need to consider fluoride levels in drinking water. e Careful monitoring of caries progression and prevention program. From American Academy of Pediatric Dentistry. Guideline on caries-risk assessment and management for infants, children, and adolescents. Pediatr Dent. 2016;38(Special issue):142–149. b

with the patient only or, if indicated, with both the patient and the parents. At this age the adolescent may enjoy independence from the involvement of his or her parents. Therefore the dentist must decide the extent of parental inclusion in the dietary consultation. The sense of independence among adolescents often leads to snacking at will. Such poor eating habits are a major factor in the increasing rates of childhood obesity.3,4 Often these poor eating patterns carry over into adulthood. There has been a notable change in snacking habits of adolescents since the 1970s.5 Several troubling issues have been identified: • The number of adolescents who snack on a given day increased from 74% in 1977 to 1978 to 98% in 2005 to 2006. • The main contributor of snacking calories is desserts. • Snacking, which accounted for 300 calories a day in 1977 to 1978, accounted for 526 calories a day in 2005 to 2006.6 • Children are moving toward constant eating. The busy lifestyles of adolescents nowadays make the sit-down family meal a rarity. This has a deleterious effect on the dietary patterns of adolescents. Research has shown that parental presence at family evening meals exerts substantial influences in terms of increasing the adolescents’ consumption of fruits, vegetables, and dairy products while lowering the consumption of soft drinks.7 A growing trend among adolescents is the consumption of sports drinks and energy drinks. Adolescents, as well as their parents,

often fail to recognize the difference between these two.8 Sports drinks are promoted by the beverage industry as products that optimize athletic performance by replacing fluid and electrolytes lost in vigorous exercise. In contrast, energy drinks purport everything from an increase in energy and a decrease in fatigue to enhanced mental alertness and focus. Many of the ingredients have minimal therapeutic benefit and are not well regulated. Energy drinks typically contain a blend of stimulants that include caffeine, taurine, ginseng, guarana, L-carnitine, and creatine. Some of these energy drinks exceed 500 mg of caffeine in a single serving, which is equivalent to the amount of caffeine found in 14 cans of the typical caffeinated soft drink.9 Caffeine tends to increase blood pressure, heart rate, gastric secretions, body temperature, cardiac arrhythmias, and diuresis.10 Studies have shown that, although the consumption of caffeine is poorly correlated with anxiety, it may result in increased anxiety for those individuals prone to anxiety disorders.11,12 Unfortunately, the sales of energy drinks continue to increase largely due to marketing efforts which target youth under 18 years of age.13 Both parents and school systems are recognizing the harmful dental effects of carbonated sodas and similar beverages and are limiting the exposure of adolescents to them. Unfortunately, these carbonated beverages are frequently being replaced with sports drinks. The pH of most sports drinks is in the acidic range (pH 3 to 4), which is well within the range to cause enamel



demineralization.14 It is unfortunate that parents and school administrators are failing to recognize the deleterious effects of sports drinks on the dentition. The AAP Committee on Nutrition (CON) and the Council on Sports Medicine and Fitness (COSMF) recently published a report with the following recommendations to pediatricians15: • Improve the education to both parents and children on the differences between, as well as the potential health risks of, sports drinks and energy drinks • Understand the potential health risks that energy drinks pose as a result of their stimulant content • Counsel at-risk individuals as to the relationship between both obesity and dental erosion to excessive sports drink consumption • Educate patients and parents on effective hydration management, stressing that water should be the initial beverage of choice for hydration purposes In 2007 the Institute of Medicine recommended prohibiting energy drink use in children and adolescence, including athletes. According to the commission’s report, energy drinks have no place in the diet of adolescents.16 Although sports drinks and energy drinks are a somewhat new trend among adolescents, the problem associated with the consumption of high-sugar beverages of any type is long-standing in this age group. Sugar-sweetened beverages have become the largest source of added sugars in the diet of adolescents in the United States.17 These beverages include nondiet sodas, sweetened fruit juices, sweetened coffee and tea drinks, and the sports and energy drinks. Some studies are attributing the increased caloric intake associated with the consumption of these beverages as a factor that is contributing to the increasing obesity rates among adolescents.18 In addition, the high sugar content of sugar-sweetened beverages has been shown to increase the risk of type 2 diabetes by increasing the dietary glycemic load, leading to insulin resistance and β cell dysfunction.19 Data from the 2011 to 2012 and 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) revealed that 62.9% of youth 2 to 19 years of age drank at least one sugar-sweetened beverages daily, and nearly 20% drank two daily.20 The elevated consumption of these beverages not only affects the overall general health of adolescents in the form of increasing rates of obesity and diabetes but also has deleterious effects on the caries rates of adolescents. Dental professionals should discuss both the dental and physical risks associated with excessive sugar-sweetened beverage consumption as part of their prevention program targeted toward adolescents. It is critical that this topic be discussed with the parents or legal guardians of those patients with special health care needs because these individuals often possess obstacles that preclude the maintenance of adequate oral hygiene. The addition of sugar-sweetened beverages in such an oral environment places the special needs patient at risk for the development of rampant caries. For the patient who has active lesions in the developing permanent dentition, dietary management and modifications are definitely indicated along with a comprehensive program of oral cleaning and daily topical fluoride use. Developing a complete understanding of the importance of this approach with the patient and determining his or her willingness to cooperate are critical to achieving a successful outcome. If the patient is interested and willing to cooperate, a dietary history may be indicated. If not, it will be only a paper exercise and a waste of time for both parties involved.

CHAPTER 39  Prevention of Dental Disease

591

Initially, a 24-hour dietary history is usually sufficient. Based on the history and additional information from patients about their typical daily schedule and academic, athletic, and social obligations, the dentist or staff responsible for counseling can assist in devising an individualized preventive plan. Having the patient acknowledge problems and commit either orally or in writing to recommended interventions can help to improve compliance. During periodic examinations, the patient’s progress or lack of progress can be evaluated. Plans may have to be modified repeatedly depending on the patient’s changing needs. Because food preferences, social pressures, and growth changes occur frequently, any plan must allow for flexibility. Although 24-hour diet histories are helpful, more insight can be obtained from a 5- or 7-day history that includes weekends. For improved accuracy, the patient should complete the first day’s record with the dentist, paying particular attention to all liquid and solid foods consumed both at meals and between meals. Information about how much of the food was consumed and where the food was eaten is helpful. After the dietary history has been completed, a staff person assigned to counseling responsibilities should carefully review it with the patient. Foods high in refined carbohydrates or retentive to the oral tissues should be identified. Intake of fresh fruits and vegetables should be noted and commended. Unusual foods or dietary patterns should be noted, and the overall balance of the diet should be evaluated. Patients should be asked to list problem areas and categorize them according to the ease with which they can be changed. With problems identified and listed according to perceived ease of modification, the patient then develops a plan. It is important that it be the patient’s plan and not the dentist’s. It is the dentist’s role to guide the patient to develop a realistic plan that will build on successes. Periodic reviews can help to determine the status of the dietary modifications and the need for new strategies. Reinforcements and rewards may be helpful, but in the end the patient’s own perception of success will likely prove to be the most rewarding aspect for both dentist and patient. A referral to a registered dietitian should be considered for the adolescent or parent who desires more intensive or more frequent dietary counseling. Consultation with a dietitian would also be useful for patients whose overall health is compromised by their dietary habits. Numerous phone apps and web-based diet analysis programs are available that provide the opportunity to track daily food and beverage consumption. These programs typically analyze the overall diet quality and provide a score or grade. Several of the programs address the amounts of saturated fat, trans fat, cholesterol, and sodium consumed in an individual’s diet. The score or grade represents compliance with established food consumption guidelines. The most common set of guidelines are those established by the US Department of Agriculture (USDA). The USDA has been establishing dietary guidelines since 1916. In 2011 the USDA’s MyPyramid food guidance system was replaced with an updated set of guidelines titled MyPlate (see Fig. 20.2). These guidelines target specific populations that include preschoolers 2 to 5 years of age, children 6 to 11 years of age, and pregnant and breastfeeding women, as well as dieters. Guidelines for adolescents are included in the section for children. Dietary challenges for patients with developmental disabilities can be substantial. Depending on the severity of the disability, dietary habits may or may not be affected. For the patient with severe neuromuscular involvement, diet and eating methods will

592

Pa rt 5

Adolescence

already have been modified. Parents or caretakers must be made aware of the potentially devastating oral effects caused by pouching, which is the prolonged holding of food in the mouth, and rumination, which is the regurgitation, rechewing, and reswallowing of food. Some patients with developmental disabilities may suffer from gastrointestinal efflux, which may cause enamel erosion. Many of these patients are on medications that cause xerostomia. If management of the diet is not possible, or if medications are an issue, efforts should be made to ensure more frequent and thorough cleansing of the oral cavity as well as frequent use of topical fluorides and sialagogues, if indicated.

Home Care Personal hygiene, like any established societal activity, is met with varying responses during adolescence. Nagging by the parent or dentist will often lead to a negative response. When an adolescent patient understands the importance of oral hygiene and is ready to make a daily commitment to it, the dentist can assist him or her in developing a routine that will be acceptable to the patient and maintain a healthy oral environment. During this period, dental flossing should become a part of the daily oral hygiene routine. Adolescents should have welldeveloped hand-eye coordination and fine motor activity. Those who have difficulty with the traditional method of flossing may benefit from a floss holder (Fig. 39.2). The goal for the adolescent should be to perform thorough tooth brushing with a fluoridated toothpaste at least twice each day, ideally at the start of the day and at bedtime. After meals, a vigorous rinse with water should be encouraged. If orthodontic appliances are present, additional time, as well as modifications of the routine, will be necessary to remove not only the plaque but also the debris caught around the brackets and wires (Fig. 39.3). Additional attention to maintain healthy marginal gingiva is also important. Effective daily home care is essential for the adolescent patient with a developmental disability. Again, depending on the severity of the disability, the patient, the parent, or a caregiver must take responsibility for the care. Mouth props may be necessary for some patients who are unable to keep their mouths open for oral care routines (see Fig. 24.5). Chemical agents that alter plaque, such as chlorhexidine and xylitol, have become popular adjuncts to daily oral hygiene in select patients. Patients who may benefit from the daily use of

these agents include those with special health care needs, as well as those with orthodontic appliances. Studies have confirmed the improvement from the use of various antimicrobial agents in reducing plaque, gingivitis, and gingival bleeding sites.21–23 Adolescents frequently experience marginal gingivitis secondary to plaque deposits. Consideration should be given to prescribing antimicrobial mouthrinses to complement daily oral hygiene practices for such individuals.24 For those patients with developmental disabilities or medical conditions that limit their ability to rinse and spit, an alternative application method is to apply chlorhexidine as a varnish or gel. Chlorhexidine varnish, although commonly used for years in European and Scandinavian countries, did not become commercially available in the United States until 2011. Studies have shown that the effectiveness in reducing mutans streptococci levels is greater with the chlorhexidine varnishes than it is with the gels or mouthrinses.25 Although the benefits of chlorhexidine on gingivitis are readily accepted, the benefits of chlorhexidine as a caries control agent are inconclusive.25 Newer studies have suggested that probiotic mouthrinses may provide a natural defense against harmful oral bacteria.21 Most studies on the effects of xylitol on caries rates focus on mothers and young children. Studies on the effects of xylitol on caries rates in adolescents are limited and have confounding results. Although the AAPD recognizes the benefits of sugar substitutes such as xylitol and advocates their use as a preventive measure for children and adolescents, they do not address a specific application schedule of xylitol for adolescents.26 More research on the subject is encouraged.

Fluoride Administration Approach to the Adolescent Patient Although most adolescents have the ability to carry out effective oral hygiene procedures, many neglect to perform these activities regularly. The key to promoting effective caries prevention during what can be a hectic and trying stage of life often depends on recognizing the predominant motivational factors operating in this age group and adopting an approach that is based on less than ideal compliance. The focus on personal appearance and hygiene in this age group can be used as a powerful motivator for developing preventive activities. Another strategy involves appealing to the adolescent’s desire to be viewed as autonomous and capable of taking care of him- or herself.

• Figure 39.3 • Figure 39.2

 

Floss holders. (Courtesy Practicon Dental, Greenville, NC.)

  Use of an interproximal brush to clean around brackets. (From Darby ML, Walsh MW. Dental Hygiene: Theory and Practice. 3rd ed. St Louis: Saunders; 2010.)

CHAPTER 39  Prevention of Dental Disease



Regardless of the psychological basis for the motivation, time should be taken to ensure that adolescents understand the nature of the disease processes that the preventive programs are addressing and the general mechanisms by which the prescribed measures are thought to counteract these processes. This emphasis on education is more likely to be accepted and will produce better long-term outcomes than a more authoritarian or condescending approach.

Caries Activity During Adolescence In spite of a well-documented decline in caries levels in children in the United States and other Western countries over the past 50 years, adolescence still marks a period of significant caries activity. A comparison was made on the data collected by the NHANES from the reporting period of 2011 to 2012 and the reporting period 1988 to 1994. In 2011 to 2012, 50% of 12- to 15-year-olds and 67% of 16- to 19-year-olds had experienced dental caries in their permanent teeth.27 These numbers reflect a decline in caries experience from the earlier 1988 to 1994 data of 57% (a 7% decline) in the 12- to 15-year-old group and 78% (an 11% decline) in the 16- to 19-year-old group.28 Despite the significant decline, the 16- to 19-year-olds still had the highest caries rates of any child or adolescent age group evaluated. These older adolescents also had the highest rate of untreated decay, at 19% compared with 12% of those aged 12 to 15.27 Therefore fluoride administration for the adolescent patient should continue to be an important concern during this stage of continuing caries susceptibility. Topical fluorides along with occlusal sealants are the primary preventive agents of choice during adolescence because the entire permanent dentition except for third molars have typically erupted by 13 years of age.29 Most studies have shown that fluorides reduce the incidence of smooth-surface caries to a greater extent than that of occlusal caries.29 Therefore the combination of fluoride therapy and occlusal sealants (Fig. 39.4) can be used to provide optimal protection for all surfaces of both anterior and posterior teeth.

593

High-Frequency/Low-Concentration Applications As with younger children, the daily use of a fluoride dentifrice should form the foundation of a sound personal preventive oral health program, regardless of whether the person lives in a fluoridated or a nonfluoridated community. Additional protection can be provided by the daily use of a 0.05% sodium fluoride rinse for those at elevated risk for the development of caries. Although these rinses are not as effective as brushing with an over-the-counter fluoridated dentifrice, they are advisable for those “on-the-go” teenagers who do not take the time to practice thorough plaque removal. Frequent exposures to fluoride may help to suppress the cariogenic potential of the oral flora and can help to establish an environment that may inhibit demineralization or promote remineralization.30 As noted previously, fluoride mouthrinses also are indicated for persons who have difficulty removing plaque because of the presence of orthodontic appliances or for those with predisposing medical conditions.

Highly Concentrated Fluoride Agents Frequent applications of highly concentrated fluoride gels, dentifrices, or varnishes may be indicated for adolescents who exhibit poor oral hygiene or other risk-elevating factors, or who continue to exhibit high levels of carious activity at recall examinations. Gels can be applied at home by brushing or by means of customized plastic trays. Custom trays are easily fabricated using vacuumforming devices that adapt plastic tray material over stone models of the patient’s maxillary and mandibular arches. The optimum time to apply the gels is just before bedtime, which prolongs the fluoride contact with the teeth.30 Professional topical fluoride applications in the form of varnishes, gels, or foams can be applied as frequently as every 3 months for moderate or high caries adolescents. An additional preventive regimen for the high caries risk adolescent with a history of ongoing caries activity is prescribing a highly concentrated fluoride dentifrice (1.1% sodium fluoride, 5000 ppm) for daily use. Individuals who use such highly concentrated fluoride products must be able to expectorate appropriately; therefore their use in some patients with special needs may be limited. Adolescence is a time of heightened caries activity for many individuals as a result of increased intake of cariogenic substances and inattention to oral hygiene procedures. Because fluorides have been shown to exert a greater anticaries effect in patients with higher baseline levels of caries activity and because the concurrent use of various forms of fluoride often produces greater caries reductions than when the agents are used separately, multiple exposures to a variety of fluoride sources should be encouraged during this period of elevated risk in an attempt to control the caries process.

Risk Factors Intraoral and Perioral Piercings

• Figure 39.4

 

Occlusal sealant. (Courtesy Dr. Dennis J. McTigue.)

A growing interest among adolescents is body modification through intraoral and perioral piercings. This mode of self-expression carries risks and complications not typically experienced with more traditional types of body piercings. The increase in complications is related to the fact that these piercings involve violations of bacteriarich mucosa that is more sensitive to disruption than would be

594

Pa rt 5

Adolescence

dermal tissue. Complications can be categorized as immediate or delayed, as well as localized or systemic. Immediate complications occurring at the time of piercing include pain, excessive bleeding, and nerve damage causing immediate paresthesia. It is also possible that infectious diseases, such as hepatitis B and C, and microorganisms responsible for the development of cellulitis and bacterial endocarditis could be introduced at the time of piercing through improper aseptic techniques. Delayed complications include the formation of tissue defects both at the site of the piercing and on tissue adjacent to the jewelry. Ninety-seven percent of patients reported some form of delayed complication.31 Fractured teeth, allergic reactions to metals, ingestion and aspiration of jewelry parts, dysphasia, masticatory problems, and hypersalivation are additional complications that have been attributed to intraoral and perioral piercings.32 Although numerous case reports are available on the subject of complications associated with intraoral piercings, relatively few large studies have investigated the subject. What studies are available reveal a strong correlation between piercings and specific types of dental injuries and pathologic conditions. The most commonly reported dental conditions include fractured teeth and the development of mucogingival defects. Loss of tooth structure due to attrition or fracture has been reported to be as high as 80% in individuals with pierced tongues (Fig. 39.5).33 Similarly, studies have reported that 19% of individuals with pierced tongues experienced some type of gingival recession.34 Because of the high incidence of complications associated with perioral and intraoral piercings, dental professionals should react proactively to those adolescents contemplating piercings. Increasing social acceptance is making it hard to identify those adolescents at risk. Therefore dental professionals should include a discussion of the complications of perioral and intraoral piercings as part of their routine prevention program aimed at all adolescents. Those adolescents who present with existing piercings should be counseled as to their risks and possible complications. Because of the rapid development and progression of tissue defects related to piercings, it may be best to keep individuals with existing piercings on shorter recall schedules than what might otherwise be dictated from their caries risk assessments.

Adolescent Pregnancy In 2015 the birth rate in the United States was 22.3 live births for every 1000 teenagers of ages 15 to 19 years.35 Although the trend in teenage birth rates has been declining, it is estimated that more than 232,000 teenagers give birth each year.35 Dentists who treat adolescent patients are likely to encounter pregnant teenagers at some time. When dealing with the pregnant teenager, the dental professional must address a unique set of issues. These would include legal concerns, emotional considerations, and distinct physical and dental problems that would not otherwise be encountered if the patient were not pregnant. The AAPD recommends that the initial evaluation of a pregnant adolescent takes place during her first trimester.36 Adolescents who are pregnant are often reluctant to share this information with their dental professional, particularly early on in their pregnancy. This reluctance to divulge information on the pregnancy makes it challenging for the dental professional to provide the anticipatory guidance and treatment that ideally would be initiated at this time. It is possible that the individual responsible for consenting privileges of an adolescent could change due to a pregnancy. State laws vary widely as to who can consent to treatment for the pregnant adolescent. Treating dentists must be aware of the local statutes that address this situation, as well as those statutes that address the confidentiality of the situation. Ideally, a dental prophylaxis should be completed during this first trimester. If either adverse periodontal conditions develop or inadequate home hygiene is noted, additional hygiene appointments should also be scheduled during the second and third trimesters. Counseling during this first visit should address dietary considerations, the consequences of hormonal changes on gingival health, and a preventive plan that includes measures to reduce the likelihood of postpartum vertical transmission of mutans streptococci to the newborn. Radiographs with adequate shielding can be taken during this first trimester but are recommended only if they will affect immediate patient care. Nitrous oxide is discouraged at this time. If elective treatment is indicated, it should be completed during the second trimester and only if it is likely to prevent the development of dental complications. Otherwise, it would be best to delay such elective treatment until after delivery. The pregnant patient who is suffering pain or infection should be taken care of immediately, regardless of the trimester of pregnancy. Any administered or prescribed medications should not pose a risk to either the expectant mother or her fetus. Fluoride supplementation is not recommended as a means to provide added protection to the developing teeth of the fetus. Often these patients will experience nausea and vomiting, which can lead to enamel erosion. An acid-neutralizing rinse should be recommended after episodes of emesis. Rinsing with a teaspoon of sodium bicarbonate mixed in a cup of warm water can provide this neutralizing effect.37 In addition, immediate toothbrushing should be discouraged. The dentist who is adequately prepared can be a strong advocate for the health and well-being of both pregnant adolescents and their unborn children. It is imperative that the dental professional who treats adolescents become familiar with the possible complications as well as the recommendations for treating pregnant patients.

Smoking and Smokeless Tobacco • Figure 39.5

  A fractured lower left first permanent molar associated with an intraoral piercing. (Courtesy Maia Rodrigo.)

The use of tobacco by minors is a complex issue. The data are clear that tobacco has both systemic and local impacts on the



body. Cardiovascular disease (stroke, heart attack, and hypertension), lung disease, and cancer of the oral and respiratory tract are wellknown sequelae associated with smoking.38 Periodontal disease also is more prevalent in smokers.39 Although most oral cancers occurs after 30 years of age, they can occur earlier.40 Therefore routine dental examinations on adolescents should include an inspection of all mucosal, tongue, palatal, and oropharyngeal surfaces to rule out the presence of oral cancers. Smoking cessation is difficult at best. The social and environmental cues that reinforce the smoking habit, combined with the potential nicotine addiction, make this a tough problem to conquer. This may be compounded in adolescents where both the habit and the search for help are often clandestine. Certainly, educating children and adolescents and preventing tobacco use is the preferred approach. When the habit has been acquired, the best cessation results appear to be those in which behavioral support is combined with nicotine replacement therapy (NRT).41 Clinicians should attempt an intervention because they can potentially cause a great impact on the well-being of an adolescent.42 Patients willing to try to quit tobacco use should be provided treatments identified as effective, and patients unwilling to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.41 The latter can be an unstructured and informal discussion of the reasons to quit and the barriers that the patient might encounter. Working with parents and children in a cessation regimen incorporating NRT requires parental consent because doing so otherwise would be a violation of US Food and Drug Administration regulations, even though those under 18 years of age have ready access to tobacco products on most occasions.43 Smokeless tobacco appears to be an increasingly popular alternative to smoking, especially among young males, for whom it increased from 0.7% in 1970 to 7% in 2014.44 More distressing, the prevalence among male high school students is near 10%.44 Smokeless tobacco can easily be used to achieve the same effects of nicotine without impinging on family, friends, and smoke-free environments. Whether smokeless tobacco is implicated in oral cancer is important because since 1970 through 2004 the 5-year survival rate of oral cancer victims has increased, but only by 15%.45 Like smoking, the environment (e.g., certain social situations) can provide behavioral cues that stimulate the desire to use smokeless tobacco.46 Aside from the unsightly necessities that accompany some smokeless spit tobaccos, there are other side effects that make it a questionable health practice. The potential for nicotine addiction is high with all types of tobacco products.47 Certainly long-term use of nicotine in any form carries the risk of hypertension. Blood pressure monitoring indicates that such changes follow tobacco users of any type.48 Furthermore, it appears that smokeless tobacco is a gateway drug to cigarettes.49,50 Smokeless tobacco has several deleterious effects on oral health. There appears to be greater risk of localized periodontal attachment loss in the form of gingival recession in smokeless tobacco users, commonly adjacent to where the tobacco is placed.51 There also appears to be a greater risk of leukoplakia developing among smokeless tobacco users,52 including adolescent users.53 Fortunately, there is good evidence that suggests smokeless tobacco keratosis (Fig. 39.6) is largely reversible.54 A major area of dispute is whether smokeless tobacco is a likely cause of oral cancer. The evidence is not decisive but points in that direction.52,55 It is not unreasonable to counsel patients and help them with cessation programs so that they can prevent the transient and possibly more morbid potential

CHAPTER 39  Prevention of Dental Disease

595

• Figure 39.6

  Clinical appearance of white lesion associated with smokeless tobacco (tobacco pouch keratosis). (From Ibsen OAC, Phelan JA. Oral Pathology for the Dental Hygienist. 5th ed. St Louis: Saunders; 2009.)

effects of smokeless tobacco, as well as the potential systemic side effects. Just as with smokers, cessation programs using a combined behavioral and pharmacologic approach can and should be initiated by dentists for their patients who use smokeless tobacco. These can be self-help programs or those with more personal interactions. Data indicate some substantial success with these types of cessation interventions.56 Some methods such as NRT may be difficult without parental involvement, given the restrictions for NRT. Enhancing this difficulty is the fact that most smokeless tobacco users do not associate this form of tobacco use with nicotine addiction. In addition to the long-lasting concerns with smoking and smokeless tobacco use among adolescents is the more recent concerns with the increasing usage of e-cigarettes and marijuana use among adolescents as detailed in Chapter 37.

Transitioning to Adulthood In 2011 the AAP in conjunction with the American Academy of Family Physicians and the American College of Physicians released a report that provided guidelines on the transitioning of youth from a pediatric medical home to appropriate adult care. A detailed health care transition algorithm was developed that outlined the steps involved to facilitate a smooth transition.57 The transition of adolescent dental patients to adult dental care is equally if not more complicated than that of medical care. It is a process that is best accomplished with some advance planning. Borrowing from the medical model, the smooth transition of adolescents from a pediatric dental home to one with an adult focus should involve three key components: provider readiness, family readiness, and adolescent readiness. Provider readiness involves the establishment of an office policy that addresses the age as well as the process for referring an adolescent to an adult dental provider. The AAPD does not require transfer by a specific age yet recommends that it be “at a time agreed upon by the patient, parent, and pediatric dentist.”58 The trend among pediatric dentists is that these transfers are taking place at an early age. Studies have found that, in the majority of pediatric dental practices, less than 10% of patients are between 15 and 21 years of age.59 Family readiness describes the practice of informing the parent or legal guardians of the established office policy well in advance

596

Pa rt 5

Adolescence

of when an actual transfer may occur. The family may need to investigate benefit coverage issues and may elect to do reference checks on potential recipients of the transfer. Adolescent readiness would be the final key component in the transfer process. It is possible that there could be emotional concerns for the adolescent who, essentially, grew up with and became comfortable with a single pediatric dental provider. Discussion of the transfer would serve the patient best if initiated well in advance of the actual transfer. Doing so could potentially help the provider recognize and address any anxiety associated with the transfer process. In addition, it could allow anxious adolescents to mentally prepare for their new dental home. It is estimated that 750,000 adolescents with special health care needs reach adulthood each year.60 These patients pose a unique set of challenges to the transfer process. Although nearly 95% of pediatric dentists routinely see patients with special health care needs, less than 10% of general dentists see these same patients.61,62 The cooperative abilities of these patients may require some behavior guidance techniques best implemented by a pediatric dentist, but their dental needs may require expertise beyond the skill set of a pediatric dentist. The complexity of these cases is highly varied, and the need for transfer should be considered on an individual basis. Some special needs patients would transition quite well to an adult practice, whereas others may be better served if they remained in a pediatric-based practice their entire life. Often, coordination is needed between multiple dental as well as medical specialties to provide optimum care for these individuals. The key is that these patients have an established dental home through which such care can be coordinated. If a special needs patient is transferred from a pediatric to an adult-based practice, it is imperative that the continued coordination for optimum care be carried out by the newly established dental home.

References 1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. National Center for Health Statistics. Vital Health Stat 11. 2007;(248):1–92. 2. Beck JD, Arbes SI Jr. Epidemiology of gingival and periodontal disease. In: Newman MG, Takei H, Klokkevold PR, et al, eds. Carranza’s Clinical Periodontology. 10th ed. St Louis: Saunders Elsevier; 2006:117–119. 3. Skinner AC, Perrin EM, Skelton JA. Prevalence of obesity and severe obesity in US children 1999-2014. Obesity J. 2016;24:1116–1123. 4. Fungwe T, Guenther PM, Juan WJ, et al. The Quality of Children’s Diets in 2003-04 as Measured by the Healthy Eating Index 2005, Nutrition Insight 43. Washington, DC: Center for Nutrition Policy and Promotion, US Department of Agriculture; 2009 April. 5. Piernas C, Popkin BM. Trends in snacking among US children. Health Aff. 2010;20(3):398–404. 6. Food Surveys Research Group. Snacking Patterns of U.S. Adolescents; September, 2010, Dietary Data Brief No. 2. 7. Fulkerson JA, Larson N, Horning M, et al. A review of associations between family or shared meal frequency and dietary and weight status outcomes across the lifespan. J Nutr Educ Behav. 2014;49(1):2–19. 8. O’Dea JA. Consumption of nutritional supplements among adolescents: usage and perceived benefits. Health Educ Res. 2003;18(1):98–107. 9. Berger AJ, Alford K. Cardiac arrest in a young man following excess consumption of caffeinated “energy drinks.” Med J Aust. 2003; 190(1):41–43. 10. Nawrot P, Jordon S, Eastwood J, et al. Effects of caffeine on human health. Food Addit Contam. 2003;20(1):1–30. 11. Bonnett MH, Balkin TJ, Dinges DF, et al. The use of stimulants to modify performance during sleep losss: a review by the sleep deprivation

and Stimulant Task Force of the American Academy of Sleep Medicine. Sleep. 2005;28(9):1163–1187. 12. Diogo LR. Caffeine, mental health, and psychiatric disorders. J Alzheimers Disease. 2010;20:S239–S248. 13. Harris JL, Munsell CR. Energy drinks and adolescents: what’s the harm? Nutr Reviews. 2015;73(4):247–257. 14. Shaw L, Smith AJ. Dental erosion—the problem and some practical solutions. Br Dent J. 1999;186(3):115–118. 15. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics. 2011;127(6):1182–1189. 16. Institute of Medicine. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth. Washington, DC: National Academies Press; 2007. 17. Reed J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc. 2010;110(10):1477–1484. 18. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357(9255):505–675. 19. Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33(11):2477–2483. 20. Rosinger A, Herrick K, Gahche J, et al. Sugar-Sweetened Beverage Consumption Among US Youth, 2011-2014. NCHS Data Brief 271. Hyattsville, MD: National Center for Health Statistics; 2017. 21. Harini PM, Anegundi RT. Efficacy of a probiotic and chlorhexidine mouth rinses: a short-term clinical study. J Indian Soc Pedod Prev Dent. 2010;28(3):179–182. 22. Manikandan D, Balaji VR, Niazi TM, et al. Chlorhexidine varnish implemented treatment strategy for chronic periodontitis: a clinical and microbial study. J Pharm Bioall Sci. 2016;8(suppl 1): 133–137. 23. Brightman LJ, Terezhalmy GT, Greenwald H, et al. The effects of a 0.12% chlorhexidine gluconate mouthrinse on orthodontic patients aged 11 through 17 with established gingivitis. Am J Orthofac Dentofac Orthop. 1991;100:324–329. 24. Bhat M. Periodontal health of 14- to 17-year-old U.S. school children. J Public Health Dent. 1991;51:5–11. 25. Autio-Gold J. The role of chorhexidine in caries prevention. Oper Dent. 2008;33(6):710–716. 26. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on the use of xylitol. Pediatr Dent (special issue). 2016;38: 47–49. 27. Dye BA, Thornton-Evans G, Xianfen L, et al. Dental Caries and Sealant Prevalence in Children and Adolescents in the US, 2011-2012, NCHS Data Brief, 191. Hayttsville, MD: National Center for Health Statistics; 2015. 28. Beltrán-Aguilar ED, Barker LK, Canto MT, et al. Surveillance for dental caries, dental sealants, tooth retention, edentulism, and enamel fluorosis—United States, 1988-1994 and 1999-2002. MMWR Surveill Summ. 2005;54(3):1–43. 29. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2001;50(RR–14):1–42. 30. Castellano JB, Donly KJ. Potential remineralization of demineralized enamel after application of fluoride varnish. Am J Dent. 2004;17(6):462–464. 31. Viera EP, Ribeiro AL, Pinheiro Jde J, et al. Oral piercings: immediate and late complications. J Oral Maxillofac Surg. 2011;69(12):3032–3037. 32. Titus P, Smily T, Francis G, et al. Ornamental dentistry-An overview. J Evol Med Dent Sci. 2013;2(7):666–676. 33. Leichter JW, Monteith BD. Prevalence and risk of traumatic gingival recession following elective lip piercing. Dent Traumatol. 2006;22(1):7–13. 34. Campbell A, Moore A, Williams E, et al. Tongue piercing: impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontol. 2002;73:289–297.



35. Martin JA, Hamilton BE, Osterman MJK, et al. Births: Final Data for 2015. Hyattsville, MD: National Center for Health Statistics; 2017. National Vital Statistics Report, 66(1). 36. American Academy of Pediatric Dentistry. Guideline on oral health care for the pregnant adolescent. Pediatr Dent. 2016;38(special issue):163–170. 37. New York State Department of Health. Oral Health Care During Pregnancy and Early Childhood: Practice Guidelines; August 2006. 38. US Department of Health and Human Services (USDHHS). The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta: USDHHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health 62; 2004. 39. Bergström J. Tobacco smoking and chronic destructive periodontal disease. J Odontol. 2004;92(1):1–8. 40. Howlader N, Noone AM, Miller D, et al, eds. SEER Stat Fact Sheets: Oral Cavity and Pharynx, 1975–2014. Bethesda, MD: National Cancer Institute; 2004. http://seer.cancer.gov/statfacts/html/oral/ cav.html. Accessed May 24, 2017. 41. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2000. 42. Demers RY, Neale AV, Adams R, et al. The impact of physicians’ brief smoking cessation counseling: a MIRNET study. J Fam Pract. 1990;31(6):625–629. 43. Johnson KC, Klesges LM, Somes GW, et al. Access of over-the-counter nicotine replacement therapy products to minors. Arch Pediatr Adolesc Med. 2004;158(3):212–216. 44. Centers for Disease Control and Prevention. Smokeless tobacco use in the United States. https://www.cdc.gov/tobacco/data_statistics/ fact_sheets/smokeless/use_us/index.htm. Accessed August 17, 2017. 45. National Institute of Dental and Craniofacial Research. Oral cancer 5 year survival rates by race, gender, and stages of diagnosis. http:// www.nidcr.nih.gov/datastatistics/. Accessed June 12, 2017. 46. Coffey SF, Lombardo TW. Effects of smokeless tobacco–related sensory and behavioral cues on urge, affect, and stress. Exp Clin Psychopharmacol. 1998;6(4):406–418. 47. Benowitz NL. Pharmacology of nicotine: addiction and therapeutics. Annu Rev Pharmacol Toxicol. 1996;36:597–613.

CHAPTER 39  Prevention of Dental Disease

597

48. Bolinder G, de Faire U. Ambulatory 24-h blood pressure monitoring in healthy, middle-aged smokeless tobacco users, smokers, and nontobacco users. Am J Hypertens. 1998;11(10):1153–1163. 49. Haddock CK, Weg MV, DeBon M, et al. Evidence that smokeless tobacco use is a gateway for smoking initiation in young adult males. Prev Med. 2001;32(3):262–267. 50. Forrester K, Biglan A, Severson HH, et al. Predictors of smoking onset over two years. Nicotine Tob Res. 2007;9(12):1259–1267. 51. Robertson PB, Walsh M, Greene J, et al. Periodontal effects associated with the use of smokeless tobacco. J Periodontol. 1990;61(7):438–443. 52. Waterbor JW, Adams RM, Robinson JM, et al. Disparities between public health educational materials and the scientific evidence that smokeless tobacco use causes cancer. J Cancer Educ. 2004;19(1):17–28. 53. Creath CJ, Cutter G, Bradley DH, et al. Oral leukoplakia and adolescent smokeless tobacco use. Oral Surg Oral Med Oral Pathol. 1991;72(1):35–41. 54. Martin GC, Brown JP, Eifler CW, et al. Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. 1999;130(7):945–954. 55. Boffetta P, Hecht S, Gray N, et al. Smokeless tobacco and cancer. Lancet. 2008;9(7):667–675. 56. Severson HH, Akers L, Andrews JA, et al. Evaluating two self-help interventions for smokeless tobacco cessation. Addict Behav. 2000;25:465–470. 57. American Academy of Pediatrics, American Academy of Family Physicians; American College of Physicians, et al. Supporting the health care transition from adolescents to adulthood in the medical home. Pediatrics. 2011;128(1):182–200. 58. American Academy of Pediatric Dentistry. Guideline on adolescent oral health care. Pediatr Dent. 2016;38(special issue):155–162. 59. Nowak AJ, Casamassimo PS, Slayton RL. Facilitating the transition of patients with special health care needs from pediatric to adult oral health care. J Am Dent Assoc. 2010;141:1351–1356. 60. Seal P, Ireland M. Addressing transition to adult health care for adolescents with special health care needs. Pediatrics. 2005;115(6):1607–1612. 61. Nowak AJ. Patients with special health care needs in pediatric dental practices. Pediatr Dent. 2002;24(3):227–228. 62. Casamassimo PS, Seale NS, Ruehs K. General dentists’ perceptions of educational and treatment issues affecting access to care for children with special health care needs. J Dent Educ. 2004;68(1):23–38.

CHAPTER 39  Prevention of Dental Disease 597.e1



Case Study: Resin Infiltration Zafer C. Cehreli

Description of Resin Infiltration Masking of white spot lesions by resin infiltration is a viable noninvasive treatment approach. In most cases the infiltration technique may offer a standalone solution to arrest caries progression and to reestablish lost esthetics, whereas in more advanced cases, the same technique can be integrated with a restorative protocol to render demineralized enamel a suitable substrate for resin bonding. This case demonstrates a typical example of white spot lesions in a 9-year-old patient with some enamel loss due to bad oral hygiene (Fig. E39.1A). The extent of demineralization was not suitable for a preventive approach using remineralizing agents, while restoration of the lesions with conventional acid-etch resin composite would lead to unnecessary tissue loss. Thus a coapplication of resin infiltration and composite restoration was determined to be the most appropriate treatment approach. The resin infiltration was used to strengthen the demineralized enamel structure and to mask the white spots while providing a suitable bonding interface for the topping composite resin in the cervical region. Following isolation of affected incisors with a heavy-gauge rubber dam and floss ties (see Fig. E39.1B), the teeth were cleaned thoroughly with pumice in a slow-speed polishing cup, rinsed, and dried. The hydrochloric acid gel (Icon-Etch) was applied onto the lesions for 2 minutes (see Fig. E39.1C). The acid was rinsed off with air-water spray for 30 seconds and then dried with oil-free air for 10 seconds. The absolute ethanol solution (Icon-Dry) was applied on the desiccated tooth surface to check whether the whitishopaque coloration on the etched enamel diminished (see Fig. E39.1D). Because this was not observed clinically, two additional sets of etching, drying, and ethanol application were performed until a complete color match was obtained. After the third round of ethanol application, the enamel surface was dried meticulously, and the Icon infiltrant was applied on the enamel surface for 3 minutes in the absence of direct operating light so as to prevent premature photopolymerization of the resin (Fig. E39.2A). Following removal of excess material with a cotton gauze, the resin infiltrant was photopolymerized for 40 seconds (see Fig. E39.2B). The infiltrant application was repeated for 1 minute and light-cured. A fourth-generation bonding agent was applied on the infiltrated surface to enhance adhesion (see Fig. E39.2C), and a body-shade composite was applied on the cervical region of the teeth to restore the lost enamel contours (see Fig. E39.2C). The composite resin was finished using polishing disks and wheels. This combined noninvasive treatment approach provided strengthening of demineralized enamel, reestablishment of lost esthetics, and adhesion of a topping composite layer without the need for retentive cavity preparation (see Fig. E39.2D).

Questions 1. What is the function of Icon-Dry (absolute ethanol) in the infiltration procedure? Answer: Icon-Dry provides a preview of the final result of infiltration by wetting desiccated enamel to mask whitish-opaque discoloration. 2. Why might the resin infiltration technique be useful prior to placing a bonded restoration? Answer: It can render demineralized enamel a suitable substrate for resin bonding. 3. What type of acid is used in the resin infiltration technique? Answer: Hydrochloric acid in a gel formulation.

A

B

C

D • Figure E39.1  (A) Preoperative view showing the extent of demineralization due to bad oral hygiene. Note that the enamel layer has been lost in some regions. (B) The teeth should be isolated meticulously so as to prevent leakage of repeated applications of hydrochloric acid. The lesions appear whiter under isolation, owing to dehydration. (C) Application of hydrochloric acid gel (Icon-Etch). (D) Application of absolute ethanol (Icon-Dry) to evaluate color match and to remove residual water within the lesions.

Continued

597.e2 P a rt 5

Adolescence

A

B

C

D • Figure E39.2

  (A) Application of the Icon infiltrant. (B) The resin is photopolymerized 40 seconds for each tooth. The infiltrant application is then repeated. (C) The missing contours are restored with a body shade composite resin placed after application of a bonding agent. (D) Postoperative view, showing ultraconservative management of the demineralization lesions.