Parental attitudes on restorative materials as factors influencing current use in pediatric dentistry.

PURPOSE: The purpose of this study was to determine pediatric dentists' current practices and the perceptions about parents' opinions and how those parental preferences regarding dental materials influence dentists' practices. METHODS: A questionnaire was sent to 500 randomly selected active members of the American Academy of Pediatric Dentistry. Twenty-five items queried demographics, use of restorative materials, perceptions of parents' attitudes towards materials, and dentists' reactions to parents' concerns. RESULTS: The survey response rate was 61%. Parental concerns about materials in decreasing order were: (1) esthetics; (2) cost; (3) toxicity; and (4) durability. Parents' greatest concerns about stainless steel crowns were: (1) esthetics; and (2) cost. Among respondents, 43% followed parental preferences when challenged, and 28% currently never use amalgam. Amalgam use and the dentists' perception of parental challenge were each related to the socioeconomic status of the practice population, with lower socioeconomic practices feeling less parental challenge than higher socioeconomic practices and being more likely to use amalgam than "white" filling materials (P = .001). CONCLUSIONS: Mercury concerns occur more frequently with higher than lower socioeconomic status parents (P = .002). Stainless steel crowns are challenged based on esthetics and cost. When confronted, many pediatric dentists (43%) follow parental preferences, even when that action is contrary to their initial clinical judgment.

Effect of adhesive systems and bevel on enamel margin integrity in primary and permanent teeth.

PURPOSE: This study compared the effectiveness of self-etch and total-etch adhesive systems in bonding to the beveled and nonbeveled margins of primary and permanent teeth. METHODS: This in vitro, factorial-designed study allowed evaluation of 3 factors: (1) tooth type; (2) presence of a bevel; and (3) adhesive type. Two preparations, each including a beveled and nonbeveled margin, were completed on buccal surfaces of 60 extracted molars (30 primary and 30 permanent). Preparations were randomly assigned to self-etch or a total-etch adhesive system and restored with resin composite. After thermocycling, teeth were stained with silver nitrate, sectioned, and measured for microleakage. Statistical analysis used a repeated measures analysis of variance. RESULTS: Beveled margins had less microleakage than nonbeveled margins for primary and permanent teeth (P < .001). Total-etch had less microleakage than self-etch adhesives on primary (53% less, P < .001) and on permanent teeth (22% less, P = .01). Self-etch had considerably more microleakage when enamel margins were not beveled. Comparably less microleakage, however, was found for total-etch and self-etch in restorations with beveled margins. CONCLUSIONS: Total-etch adhesive and beveled margins resulted in the least microleakage. Margin beveling has a greater effect in minimizing microleakage than the type of adhesive used.

Amelogenin p.M1T and p.W4S mutations underlying hypoplastic X-linked amelogenesis imperfecta.

Mutations in the human amelogenin gene (AMELX, Xp22.3) cause a phenotypically diverse set of inherited enamel malformations. We hypothesize that the effects of specific mutations on amelogenin protein structure and expression will correlate with the enamel phenotype, clarify amelogenin structure/function relationships, and improve the clinical diagnosis of X-linked amelogenesis imperfecta (AI). We have identified two kindreds with X-linked AI and characterized the AMELX mutations underlying their AI phenotypes. The two missense mutations are both in exon 2 and affect the translation initiation codon and/or the secretion of amelogenin (p.M1T and p.W4S), resulting in hypoplastic enamel. Primary anterior teeth from affected females with the p.M1T mutation were characterized by light and scanning electron microscopy. The thin enamel had defective prism organization, and the surface was rough and pitted. Dentin was normal. The severity of the enamel phenotype correlated with the predicted effects of the mutations on amelogenin expression and secretion.

Guiding and managing the child dental patient: a fresh look at old pedagogy.

Society's approach to children during the past half-century has changed dramatically, and a transformation of medical and hospital pediatric care has followed. Dentistry has been slower to incorporate sound, child-friendly approaches to care. Nonetheless, much has changed in dental practice pertaining to children. The regular involvement of parents in the surgical/therapeutic suite is one such change. Expanded communication to ensure informed consent for treatment as well as consent for type of management approach to children is the standard of care. Since sedation policies are becoming more complex, enhancing the skills of all dentists and staff members in the best methods of nonpharmacological child management will be essential in the next decades. Biobehavioral methods will gain prominence, along with better communication skills of the dental team. These changes will occur only if more time and resources are positioned to teach dental students, dentists, and staff the necessary skills. Emphasis must be placed on early, timely intervention; parental involvement; effective communication; cultural competence; and the "medical/dental home" concept as methods to reduce negative dental attitudes and behaviors of children.

Water consumption and nursing characteristics of infants by race and ethnicity.

OBJECTIVES: The purpose of this project was to determine racial/ethnic differences in water consumption levels and nursing habits of children younger than 2 years old. METHODS: Data from the 1994-96 Continuing Survey of Food intakes by individuals (CSFII) were used for these analyses. Water consumption and breast-feeding data on 946 children younger than 2 years old were used. RESULTS: For black non-Hispanic children younger than 2 years old (n = 121), 5.3 percent of the children were currently being breast fed. This percentage was less than that seen in other racial/ethnic groups. For white non-Hispanic children (n = 620), this percentage was 10.8 percent; for Hispanic children (n = 146), 12.2 percent; for "other" children, 18.5 percent (n = 59). Black non-Hispanic children had the highest total water consumption (128.6 ml/kg/day) among all groups, white non-Hispanic had the lowest (113.2 ml/kg/day). These differences were not statistically significant in multivariate regression modeling. Black non-Hispanic children also drank more tap water (21.3 ml/kg/day) than white non-Hispanic children (12.7 ml/kg/day) and Hispanic children (14.9 ml/kg/day). The difference was statistically significant in multivariate regression modeling. CONCLUSIONS: The differences in breast feeding and water consumption observed among black children younger than 2 years of age could be a factor in the observed higher levels of fluorosis in black children compared to other children.

Improved sealant retention with bonding agents: a clinical study of two-bottle and single-bottle systems.

Recent in vitro work and a short clinical study suggest that adding a bonding agent layer between sealant and saliva-contaminated enamel allows for adequate bond strength and retention of resin sealants and may improve success of all sealant applications. This five-year clinical study scored 617 occlusal and 441 buccal/lingual molar sealants, with use of a split-mouth design, with half receiving sealant alone and half bonding agent plus sealant. Treatment effects and potential risk factors for sealant failure were tested by means of a Cox regression model. Three bonding agent groups were analyzed for treatment effect: Tenure primer, Scotchbond Multi-Purpose, and 3 single-bottle dentin bonding agents as a third group. The single-bottle group was successful in reducing risk of sealant failure, with a hazard ratio (HR) of 0.53 (p = 0.014) for occlusal and 0.35 (p = 0.006) for buccal/lingual sealants. Scotchbond was detrimental to occlusal sealant success, with a HR of 2.96 (p = 0.0003). Tenure primer was neutral, showing HRs close to 1.0. Variables that affected success differed between occlusal and buccal/lingual sealants, suggesting that failures on these two surfaces may be dependent upon differing factors. Early eruption stage was a significant risk factor for both surfaces (HR = 2.91, p = 0.00001, occlusal; and HR = 1.52, p = 0.015, buccal/lingual). Behavior (HR = 1.96, p = 0.0007), salivary problems (HR = 1.73, p = 0.002), and visually apparent variations in enamel (HR = 1.51, p = 0.018) were significant risk factors for occlusal sealants only. In addition to completing detailed analyses of risk factors for sealant survival, this study shows that single-bottle bonding agents protect sealant survival, yielding half the usual risk of failure for occlusal sealants and one-third the risk of failure for buccal/lingual sealants.

Bilateral versus unilateral mandibular block anesthesia in a pediatric population.

PURPOSE: This prospective study aimed to evaluate unilateral versus bilateral mandibular nerve block anesthesia with regard to post-operative soft tissue trauma and other complications in a pediatric population. METHODS: A total of 320 patients age 2 to 18 years were appointed for routine operative treatment. There were no age, gender, behavior, or general health exclusions. Oral and written post-operative instructions were given to parents, as well as a survey preview. A phone survey was conducted after treatment to determine a number of variables, including soft tissue trauma. RESULTS: A total of 13% of all patients experienced post-operative soft tissue trauma. By age group, trauma frequency was 18% (< 4 yrs.), 16% (4-7 yrs.), 13% (8-11 yrs.) and 7% (> 12 yrs.). Comparing unilateral versus bilateral subjects as to trauma revealed that in the < 4 age group trauma was higher for the unilateral subjects (35% vs. 5%, P < .02). Non-significant trends showed increased trauma in unilateral groups at ages 8-11 and > 12 years. CONCLUSION: This study represents the first documentation of post-anesthetic soft tissue trauma prevalence in a pediatric population. The results reveal no contraindication to the use of bilateral mandibular block anesthesia.

Use of one-bottle adhesive as an intermediate bonding layer to reduce sealant microleakage on saliva-contaminated enamel.

PURPOSE: To evaluate the influence of three different adhesives, each used as an intermediary layer, on microleakage of sealants applied under condition of salivary contamination. MATERIALS AND METHODS: Six different experimental conditions were compared, 3 with adhesives and 3 without. After prophylaxis and acid etching of enamel, salivary contamination was placed for 10 s. In Group SC the sealant was applied after saliva without bonding agent and then light-cured. In Group SCA, after saliva, the surface was air dried, and then the sealant was applied and cured. In Groups ScB, SB and PB, a bonding agent (Scotchbond Dual Cure/3M, Single Bond/3M and Prime & Bond 2.1/Dentsply, respectively) was applied after the saliva and prior to the sealant application and curing. After storage in distilled water at 37 degrees C for 24 hrs, the teeth were submitted to 500 thermal cycles (5 degrees C and 55 degrees C), and silver nitrate was used as a leakage tracer. Leakage data were collected on cross sections as percentage of total enamel-sealant interface length. Representative samples were evaluated under SEM. RESULTS: Sealants placed on contaminated enamel with no bonding agent showed extensive microleakage (94.27% in SC; 42.65% in SCA). The SEM revealed gaps as wide as 20 microm in areas where silver nitrate leakage could be visualized. In contrast, all bonding agent groups showed leakage less than 6.9%. Placement of sealant with a dentin-bonding agent on contaminated enamel significantly reduced microleakage (P < 0.0001). The use of a bonding agent as an intermediary layer between enamel and sealant significantly reduced saliva's effect on sealant microleakage.

Effect of chlorhexidine varnish mouthguards on the levels of selected oral microorganisms in pediatric patients.

PURPOSE: The effect of a chlorhexidine varnish delivery system on the levels of selected oral microorganisms was evaluated in caries active pediatric patients, ages 4 to 12 years old. METHODS: Forty-six patients were enrolled into the study when they had multiple carious surfaces and salivary mutans streptococci (MS) levels higher than 10(4) colony forming units (CFUs) per milliliter. This study incorporated a double-blind design and patients were randomly assigned to either the chlorhexidine treatment group or the placebo group. Complete-arch, vacuum-adapted mouthguards (0.02 in. polypropylene coping material) were custom fabricated and coated internally with either a 3.0% chlorhexidine varnish or a placebo varnish. Two pretreatment paraffin-stimulated saliva samples were obtained for culturing prior to varnish treatment. Saliva samples were also obtained immediately after treatment and once a month for up to three months after wearing the mouthguard appliances. Dental restorations were placed at most of these saliva collection visits. Mouthguards were reportedly worn for an average of 9.7 hours per night for approximately seven nights by 40 subjects (87%). RESULTS: After two months, and after three months, there was a significant reduction in MS levels immediately after the chlorhexidine varnish treatment. Total anaerobic and total facultative bacteria levels were not significantly affected. CONCLUSION: One week of nightly use of the chlorhexidine varnish mouthguard system is effective at reducing the number of MS in caries-active pediatric patients in the mixed and primary dentition for at least three months.

Preparation and beliefs of graduates of a predoctoral infant oral health clinical program.

PURPOSE: The aim of this study is to evaluate the effects of a predoctoral clinical educational program on preparation and beliefs of participants related to infant oral health. METHODS: Questionnaires were constructed and mailed out to four classes of past dental students, two of which had attended the program. RESULTS: Significant differences were detected between groups regarding their feelings of preparation for examination procedures in children younger than 36 months and their beliefs regarding appropriate age of the initial dental visit.

Sealants and preventive restorations: review of effectiveness and clinical changes for improvement.

Sealants are effective caries-preventive agents to the extent they remain bonded to teeth. Preventive resin restorations (PRR) have a proven record, but are susceptible to failure as the overlying sealant fails. Careful analyses of studies reveal a measurable failure rate of sealants (5-10% per year) that must be addressed. Even under the best of circumstances, sealants fail. Therefore, dentistry (as well as third-party systems) must accept that sealants need vigilant recall and proper preventive maintenance. In addition, it is clear that cost-effective use of sealants will involve selective application on teeth with the greatest caries risk. Caries risk analysis of the patient as well as the tooth is an essential step in the treatment planning process. To improve sealant success, new material advances are suggested. Data from studies using an intermediate layer of dentin bonding agent between etched enamel and sealant show dramatic reduction of failure for sealants, particularly in instances of molars judged difficult to seal due to early stage of eruption.

Dentin bonding: SEM comparison of the dentin surface in primary and permanent teeth.

The literature suggest differences between primary and permanent teeth regarding the composition and morphology of the dentin. The purpose of this study was to compare the effect of two dentin conditioners on the micromorphology of the dentin surface of primary and permanent teeth. Human extracted and noncarious molars were divided into four groups and conditioned with either 10% phosphoric acid (All-Bond 2) or 10% maleic acid (Scotchbond Multi-Purpose) for different time periods. SEM photomicrographs (1500x) were taken from the conditioned dentin and evaluated blindly by three calibrated examiners. The results indicate that the smear layer was removed more easily from primary teeth than from permanent teeth (P = 0.0001), which suggests greater reactivity to acidic dentin conditioners. We also found that the longer the time of application of dentin conditioner the more smear layer is removed (P = 0.0094). In comparing primary and permanent dentin, the results of this study indicate that less time is required for appropriate acid conditioning of primary dentin surfaces. Such a differentiated protocol for bonding to primary tooth dentin results in surface morphological characteristics similar to those found in conditioned permanent teeth.

Composite rebonding to stainless steel metal using different bonding agents.

The purpose of this study was to determine the in vitro bond strengths of composite rebonded to stainless steel crown metal (SS) using five different bonding agents after composite to SS bond failure had been produced. The adhesive systems were applied to the failed bonds following the manufacturers' instructions and, as a control, composite was bonded to SS without using a bonding agent. Each group was then divided into two subgroups: mechanically prepared (MP), in which the SS was roughened by a diamond bur, and unprepared (NMP), in which no modification of the SS was done. ESPE VISIO-GEM composite was placed in a plastic mold and light cured to the treated SS. Samples were stored in water at 37 degrees C for 72 hr, thermocycled for 500 cycles between 5 and 55 degrees C, and mounted in an Instron Universal Testing Machine. Caulk's Adhesive System provided significantly higher rebond strength (228.97 +/- 106.9 kg/cm2) than the other materials, and mechanical surface preparation offered no significant advantages.

Producing the next generation of professional educators in pediatric dentistry.

We will see an abundance of eager, well-prepared aspiring academic pediatric dentists only when the market forces make this decision more rational for the best and the brightest. Until then, our challenge is to show interested students the excitement and vitality of this career path through our own examples. Then, once those few are intrigued, it is incumbent upon the system to be prepared to foster their interest and help them improve their skills so they are prepared to be successful in the academic environment. In addition, supplementation of teaching efforts may come from other creative avenues. Potential additional sources are found in experienced clinicians as well as modern, media-based instructional packages.

Dentin bonding: SEM comparison of the resin-dentin interface in primary and permanent teeth.

Previous studies have suggested minor differences between primary and permanent teeth in terms of dentin composition and morphology. Other reports indicated lower bond strengths of resin composites to dentin of primary teeth compared with dentin of permanent teeth; however, no information is available regarding differences in the micromorphology of the resin-dentin interface that may explain these lower bond strengths. Therefore, the purpose of the present study was to compare primary and permanent teeth in terms of the thickness of the hybrid layer developed with two bonding systems. Our hypothesis was that bonding differences previously reported between primary and permanent dentin would be reflected in hybrid layer differences observable in SEM analyses. Twenty human extracted and non-carious teeth were divided into 4 groups: 5 primary and 5 permanent teeth restored with All-Bond 2/Bisfil P system; and 5 primary and 5 permanent teeth restored with Scotchbond Multi-Purpose/Z100. The sample area available on each tooth was divided for the two dentin conditioning times (7 and 15 sec). Measurements of hybrid layer thickness were performed by means of SEM at x13,000. The results of this study indicated that the hybrid layer produced is significantly thicker in primary than in permanent teeth (p = 0.0001), suggesting that primary tooth dentin is more reactive to acid conditioning. No difference was observed in the hybrid layers produced by the two adhesive systems (p = 0.7920). The increased thickness of the hybrid layer in primary teeth (25 to 30%) and the subsequent lack of complete penetration of adhesive resin into previously demineralized dentin may contribute to the lower bond strengths to primary dentin reported in the literature. If a narrower hybrid layer more uniformly infused with resin is the goal of dentin bonding, it is concluded that a differentiated protocol for bonding to primary dentin (with shorter time for dentin conditioning) can be used as a means to reproduce the hybrid layer thickness seen in permanent teeth.

Pediatric behavior management through nonpharmacologic methods.

All professionals who treat children must develop philosophies of care. Pediatric behavior management deserves significant attention by dentists in the development of such a philosophy. Different strategies are available to manage the variety of pediatric patients' challenges that dentists face. Yet, achieving familiarity and comfort with all of these strategies is a difficult if not impossible task. Therefore, dentists must assess which methods they can be use effectively and safely. Dentists must communicate with parents so that their informed consent is obtained for any of the strategies chosen. Knowledge of the society or community in which one works is essential in deciding which technique will be acceptable. Furthermore, methods of pediatric management are most effective if they are honest extensions of one's personality. Thus, developing a management philosophy demands that one be true to oneself. Behavior-management methods used should be based on careful assessment of one's training and experience with the methods, and evaluation of one's personal philosophy of practice. In addition, the environment in which one practices must be considered in choosing the optimum mix of management strategies with which to fill one's practice "bag of tricks".

Home-use tooth bleaching agents: an in vitro study on quantitative effects on enamel, dentin, and cementum.

Studies on home-use bleaching agents containing carbamide or hydrogen peroxide demonstrate minimal topographic alteration and insignificant organic change to tooth material. This in vitro study evaluated the effects of a three-step commercial home-use bleaching agent on extracted human incisors over time. Each tooth was digitized by baseline and sequential profilometry and analyzed using computer software. Statistically significant volume loss was evident in cementum and dentin after simulations of 4 and 8 weeks of use.