Technique notes atraumatic technique.€¦ · technique on open lesions in primary molars. Interim restorative treatments • Excavating caries The excavation technique shown below

TECHNIQUE NOTES

for

Atraumatic procedures forchild patients in outreach

dental programmes.

by Graham G Craig andKeith R Powell

Based on ‘A Handbook of Expanded Atraumatic Techniques for theApprehensive Child Dental Patient’ by GG Craig and KR Powell.

Dental Outlook Publications, 2013.

For more details of products mentioned please email Dr Graham Craig at [email protected]

Technique notes atraumatic technique. 4/10/17 2:40 PM Page 1

1

These notes are divided into 3 sections to correspond to thevarious situations encountered, including patient co-operation,and the dental equipment available for the treatment of opencarious lesions in primary molar teeth:1. Chemical treatments.2. Interim restorative treatments.3. Restorative treatments requiring rotary

instruments.

All relevant references and photographs of cases followed forup to 4 years can be found in ‘A Handbook of ExpandedAtraumatic Techniques for the Apprehensive Child DentalPatient’ by GG Craig and KR Powell. Dental Outlook 2013. Available from Dental Outlook Publicationswww.dentaloutlook.com.au

Email for Dr GG Craig - [email protected]

Foreword:


2TE

CH

NIQ

UE

NO

TES

Begin by looking at the existing lesions

• Where are they located?Although it may vary from one population group to another, there are somegeneral guidelines as to which lesions in primary molars that tend toprogress rapidly and those that do not. This is illustrated below:

slow

medium

fast

medium

medium

medium

fast

slow

Fast progression• Distal of first primary molars.• Mesial of second primary molars.• Distal of second primary molars

(when first permanent molars have erupted).

Medium progression• Occlusal of first and second

primary molars.Slow progression• Distal of canines.• Mesial of first primary molars.• Smooth facial surfaces of

primary molars.

Summary

• How open are the lesions?As a general observation the more open a lesion is to saliva, the slower itsprogression.

Above: The simple act of opening up a carious lesion (left) to the action ofsaliva can result in the arrestment or slowing down of the lesion (right).

upper

lower

Saliva has a good buffering and remineralising capacity and its effect can beutilised in the treatment of open carious lesions in primary molars.


Looking at the existing lesions (cont)

• What colour are the lesions?Invariably darker lesions are progressing more slowly than lighter-colouredones and, whilst probing of a lesion is best avoided, the darker-colouredones are usually firmer.

• If bite-wing radiographs can be taken....A considerable amount of very useful information can be obtained frombite-wing radiographs of primary molar teeth particularly regarding lesiondepth of approximal surface and occlusal lesions. Unlike the situation withpermanent teeth, in primary molar teeth the radiographic depth of a lesionusually corresponds very closely with the clinical depth.

slowerfaster

Information that can be obtained from bitewing radiographs includes:A. Depth of approximal surface and occlusal lesions.B. Presence of furcation pathology.C. Degree of root resorption and position of permanent successor.

A A

B C

Summary:The fact that a lesion may look large does not necessarily mean that itis progressing rapidly. The above information can help differentiate thelesions that are likely to progress quickly as against those with a lowerpriority.

3


• TechniqueA simple atraumatic start, especially for apprehensive child patients , is theuse of 40% silver fluoride on open carious lesions in vital, asymptomatic pri-mary molars. A number of clinical studies have shown the usefulness of silverfluoride preparations in the treatment of open carious lesions in primary teeth.

If bite-wing radiographs are available there should be approximately 0.5 mmor more of radiographically sound dentine from the base of the lesion to thepulp for open occlusal or approximal surface lesions.

Chemical treatments

If the tooth is vital and there hasbeen no history of pain the toothto be treated is isolated withcotton rolls.

a.

Any obvious food debris isremoved with an excavator. Nocaries is removed.

b.

excavation ofobvious fooddebris

The silver fluoride AgF preparationis applied on a microbrush andthe site is kept wet with thesolution for 1-3 minutes (at leastone minute)..

c.

After the silver fluoride applicationperiod 10% stannous fluoride (SnF2) isapplied as a reducing agent to turn thesurface of the lesion black.

d.

The treated site is temporarilycovered with OOrraabbaassee PPrrootteeccttiivveePPaassttee (Convatec). Experiencedoperators may prefer to use apiece of SSttoommaahheessiivvee WWaaffeerr(Convatec).

e.

Ideally, a few days later the surface of thelesion is examined to see if the entiresurface has a black mat appearance. If itdoes not, the non-pigmented area isinspected to ensure it is not a pulp expo-sure. If this is not the case, repeat theabove steps.

f.black-matsurface

microbrushwith CSDSAgF solution

microbrushwith CSDSSnF2 solution

protective paste orwafer

4


Chemical treatments (cont)

• Useful items

Junior Garmers Cotton RollHolders (Garmers) are ideal forlower arch isolation. They havethe additional advantage ofremoving the need for high vol-ume aspiration and the accompa-nying noise that may have upsetsome apprehensive youngpatients.

Tip: When using Garmers CottonRoll Holders the cotton roll ispicked up with the prong half-wayalong the roll, not at the end. Thismakes seating far easier.

pick up

point

cotton roll

Open lesions are treated with 40% silver fluoride(left) for one to three minutes followed by the useof 10% stannous fluoride (right) as a reducingagent. CSDS from Creighton Dental contains these agents.*

Silver fluoride and stannous fluoride

Garmers cotton roll holders

Temporary covering

Piece ofStomahesiveWafer withbacking

Treated sitecovered by apiece ofStomahesiveWafer.

Technique: For a small piece of Stomahesive Wafer toadhere properly to tooth structure, it has first to be thinnedand then warmed. Thinning can be achieved by pressing itbetween two glass slabs and it can be warmed by thepatient holding the piece in his or her hand. It is adaptedwith firm pressure on sound tooth structure making sure theedges are completely sealed. After adaptation the wafer isleft to dissolve in the oral fluids.

Left: Even though it does not stay aslong as the wafer (below), OrabaseProtective Paste (Convatec) is easyto apply with the gloved finger.

cut out piecewarm the wafer

Below: Experienced operators may prefer to use a piece of Stomahesive Wafer (Convatec):

5

* Available from Dental Outlook (02 9557 9330)[email protected]


One of the advantages of using stannous fluoride one minute or more afterthe application of 40% silver fluoride is that it turns the surface of the car-ious lesion black. This is a valuable indicator because if the surface becomeslighter it is an indication that the lesion may be progressing and needs clos-er inspection.*

In addition the distinctive black colour provides an indicator to other opera-tors not to intervene. Some procedures, such as with nano-silver, do notstain the surface of a lesion. In these circumstances it can be very difficultfor an operator to determine whether a lesion is stationary or progressing.Probing a surface, especially when the lesion is deep, can produceiatrogenic damage.

Chemical treatments (cont)

• How do you know it has worked?

Above: After the silver fluoride/stannous fluoride treatment,the continuing presence of a black mat on the surface of thelesion is a strong indicator that the lesion is static.

Above: Loss of the black matt surface at some stage after thesilver fluoride/stannous fluoride treatment as shown is indica-tive of lesion progression.

6

Treatments can be repeated if lesion lightening does occur.*Reference: Craig et al. BMC Oral Health 2013, 13:73


• BackgroundA standard part of the Atraumatic Restorative Technique (ART) is the use ofhand instruments to remove caries and prepare a cavity. However, there area number of subtle points that have to be kept in mind when using the ARTtechnique on open lesions in primary molars.

Interim restorative treatments

• Excavating cariesThe excavation technique shown below involves starting at the periphery ofthe lesion and working inwards. The natural undercuts produced by the lat-eral spread of caries just inside the dentino-enamel junction are used toassist in retention of the restoration.

A B C

Caries is gently excavatedstarting at the periphery ofthe lesion.

The outer areas are freedof decay before workinginwards.

To assist retention of therestoration, utilisation is madeof the natural undercuts justinside the dentino-enameljunction produced by the slightlateral spread of the lesion.

easiest hardest

Occlusallesions.

‘Box-type’approximal sur-face lesions insecond primarymolars.

‘Box-type dis-tal surfacelesions in firstprimarymolars.

Wide, butshallow, distalsurface lesionsin first primarymolars.

• Grades of difficultyThe length of service of an interim restoration, where cavity preparation iscarried out with an excavator alone, can vary with the site of the lesion. It isusually easy to obtain reasonable longevity for occlusal lesions and hardest forlesions on the distal surface of first primary molars.

7

• Tip

As an extra insurance, in case of loss of an interim restoration, it is advis-able to apply some silver fluoride to the preparation. The solution is appliedthen evaporated to dryness before the restorative material is inserted.


Interim restorative treatments (cont)

• Problem area: Distal surface of first primary molarsIt can be extremely difficult to retain an interim restoration in the distalsection of a lower first primary molar. The taper of the facial and lingualsurfaces towards the distal plus the relatively thin enamel makes retentiona problem with ‘box only ’ preparations.

The taper of the facialand lingual surfacestowards the distal plus thethin enamel in first pri-mary molars can make theretention of ‘box only’restorations a problem inthis area.

As a first step, a ‘box only’preparation may have to beused. The life-span of thistype of restoration is likelyto be limited and, as alonger-term solution, itmay be necessary to placea restoration with anocclusal lock.

• Restorative materials

As in ART, high-viscosity, glass-ionomer cement is the preferred restorativematerials for interim restorations. However, some operators have had goodresults with very thickly mixed IRM (Dentsply).

8

• Contour of an approximo-occlusal interim restoration

To increase the longevity ofinterim approximo-occlusalrestorations the marginalridge height is lowered asshown.

After placement of the glass-ionomer cement, the back of aspoon excavator is used toachieve the appropriatecontour.

noyes back of a spoon

excavator

Note: Unlike the situation with permanent teeth, the contact area withapproximo-occlusal restorations in primary molars only needs to be at somepoint above the gingival margin to prevent food impaction.


• Increasing salivary access to a lesionRotary instruments can be useful in increasing salivary access to a lesion. Twomethods are shown below:

Use of rotary instruments

With the Ingers’ Technique a sliceis made with a tapering diamondbur at an angle of approximately60 degrees or less.

The remaining caries is removedand a simple ‘box-type’ restorationplaced.

600restoration

With a co-operative patient, theIngers’ Technique is extremely use-ful for handling the problem ofdisto-occlusal cavities in firstprimary molars.

It can be used when there is no gapbetween the first and secondprimary molars at the level of thegingival margin.

Ingers’ Technique:no gap

For the Ingers’ Technique to be usedthere must be no gap at the gingivalmargin between the first and secondprimary molars.

Cusp reductioncan be used toopen up acarious lesionto the actionof saliva.

Cusp reduction:

An oval-sped diamond bur can be used for cusp reductionand so open up a lesion to the action of saliva.

9


Use of rotary instruments (cont)

• Preparation of an occlusal lockTo increase the longevity of disto-occlusal restorations in first primarymolars it may be necessary to place and occlusal lock.

Example of sharp round tung-sten carbide burs that can beused to prepare retentivefeatures for restorations in pri-mary molar teeth. They areused at 100-200 rpm in areduction handpiece (inset).These handpieces are common-ly identified by a green bandon the shank.

To reduce apprehension whenworking without local anaes-thesia it is a good idea to firstrun the round bur on thechild’s finger at a slow speed.

slowly

rotating

bur

occlusal lock

The preparation of an occlusal lock follows the shape shownand is carried out with round burs rotating slowly in an ultra-low speed handpiece. Care should be taken to ensure that thereis at least a small periphery of sound dentine, just inside thedentino-enamel junction, on the gingival floor and the buccaland lingual walls.

• Use of ultra-low speed cuttingUltra-low speed cutting can be very useful for cavity preparation in primaryteeth. It has been found that pressure from a slow moving round bur tendsto cause little or no discomfort whereas vibration does.

Tooth structure of primary teeth can be removed cleanly and efficiently byusing sharp round tungsten carbide burs in a handpiece rotating at around100 to 200 rpm.

10


Use of rotary instruments (cont)

• Cavity preparation for second primary molars

retentive grooves

Placing retentive grooves just insidethe dentino-enamel junction in anapproximal box as illustrated can beused to increase the longevity ofmesio-occlusal and disto-occlusalrestorations in second primarymolars.

A B A

Outline of cavity preparations usedon approximal surfaces of first andsecond primary molars.

A = ’box’ type. B = with occlusal lock.

As with disto-occlusal cavities in first primary molars, all the cavity prepara-tion is carried out with round burs. However, because of the greater thick-ness of enamel it is invariably not necessary to prepare an occlusal lock.

There is usually sufficient room to prepare adequate retentive grooves inthe buccal and lingual walls of the approximal box. A periphery of sounddentine, is prepared just inside the dentino-enamel junction, on the gingivalfloor and the buccal and lingual walls.

11


• Main causes of pain in primary molars

Relief of pain

The main causes of pain in the primary denti-tion appear to be:

• Pain from food impaction.

• Pain from tooth mobility caused either byimminent exfoliation or a chronic alveolarabscess.

• Possibly pulpitis.

• Very early stages of a chronic alveolarabscess before the abscess has pointed.

• Acute alveolar abscess (fortunately fairlyrare in the primary dentition).

Pain from food impaction:

Recognition:

• Patient complains of pain when chewingfibrous foods such as meat or chicken.

• There is an approximal surface lesion withthe overlying marginal ridge broken away.

• Close inspection shows fibrous food rem-nants jammed between the teeth.

• Examination of the bite-wing radiographshows a definite layer of sound dentinebetween the base of the lesion and the pulp.

Be aware of a common mistake:

A common mistake is interpreting ‘pain onchewing’ as a sign of an abscess. All indicatorsshould be taken into account before a finaldiagnosis is made.

Treatment:

• The jammed food remnants are teased outcarefully in an occlusal direction with the endof an explorer. Care should be taken not topush impacted items towards the gingivalmargin as this could invoke a pain response.

• Place a temporary restoration.

• Recall the patient the next day to ensurethat the symptoms have subsided.

• Restore the tooth.

Food impaction as shownis a common cause of painin the primary dentition.It can be misinterpretedas a sign of an abscess.

Photograph showingimpacted food removed.Note how the impactionproduced a distinct craterin the gingival tissue.

This bite-wing radiographshowed the presence of adistinct layer of sounddentine between thebase of the lesion andthe pulp. This is a usefulindicator that the causeis not of pulpal origin.

Food impaction

Treatments:

12


Relief of pain (cont)

Treatments (cont)

Once impacted food isremoved a temporary restora-tion is placed. The patient isrecalled the next day toensure that the symptomshave subsided. The tooth issubsequently restored.

Bite-wing radiographshows caries hasreached, or isextremely close to, thepulp.

It was important toexcavate right up tothe point where vitaltissue is encountered.

Food impaction (cont)

Chronic/acute abscess

Other pulp treatments

The other pulpal problems encountered with carious primary molars are achronic alveolar abscess and an acute alveolar abscess .Traditional treat-ment carried out by the authors used Kri 1 Paste (Pharmachemie) andLedermix Paste (Lederle). However, Kri 1 Paste is no longer marketed andso an alternative is required (see box next page).

Pain from pulpal involvement:

Recognition:

• Indications from patient history.

• The possible presence of swelling etc.

• Evidence from a bite-wing radiograph thatcaries had reached the pulp.

Technique:

(The process can be carried out without anaes-thesia but requires proceeding with caution).

• Caries is excavated right up to the pointwhere vital tissue is encountered. (Quite fre-quently primary molar teeth exhibiting signs ofa chronic alveolar abscess can have pulpswhich, clinically at least, are completely vital).

• If the pulp chamber is reached withoutencountering any vital tissue, the pulp chamberis entered and progress stopped when any vitaltissue was reached. (If the pulp chamber is freeof vital tissue, and the patient is co-operative,the roof is removed with a tapering bur in ahigh speed handpiece to gain better access).

Treatment:

13



The exposure site is coveredwith the iodoform/Ledermixmixture. A piece of flattenedcotton wool is placed on topand tamped into position.Finally the temporary restora-tion is inserted.

Depending on the presence or absence of vital tissue the finaldressing can be either like (a) or (b) above. Interestingly, theiodoform/Ledermix combination tends to have a devitalisingeffect on remaining pulp tissue which makes the subsequent rootfilling a lot easier.

temporary

restoration

cotton wool

paste

A B

Treatment:

The treatment with iodoform/Ledermixpaste as outlined above is followed. Withchronic alveolar abscesses experience hasshown that vital tissue may still be present(often in the pulp chamber or root canalfurthest away from the pulp exposure site).Furthermore, in some primary molar teeth >

Chronic alveolar abscess:

One type of chronic alveolar abscesspoints at or near the gingival margin,often occurs just before a badly brokendown tooth exfoliates.

Tooth mobility is often the main causeof the discomfort in these cases.

Another type of chronic alveolarabscess points in a region adjacent to aroot apex (shown above) tends to beassociated with a more long-standingpulpal involvement.

Quite often the patient is unaware thatthe abscess is present.

Two types of chronic alveolar abscess:

80.0% iodoform20.0% silicone oil(mix and homogenise)

Alternative to Kri 1 Paste

14



Treatments (cont)

Treatment: (cont)

showing signs of a chronic alveolarabscess, the pulp clinically appearsto be vital. In such cases it ispossible that the abscess repre-sents an escape of inflammatoryexudate from the pulp rather thanpus.

When treating teeth with a chronicalveolar abscess no attempt ismade to ream and file the rootcanals, instead try and introduce >

Chronic alveolar abscess:

Treatment:

Conservative treatment may be diffi-cult, however, the course of treatmentoutlined for a chronic alveolar abscessin combination with antibiotic treat-ment has been found to be successful.

Acute alveolar abscess:

some iodoform/ Ledermix paste into aroot canal with the point of a probe.

Other conditions

Chronic hyperplastic pulpitis:

A condition that can be associ-ated with grossly cariousprimary teeth is chronic hyper-plastic pulpitis. In this situationtissue grows out from theexposure site into the cavity.When it occurs it appears tocause little or no discomfort tothe patient.

Root stumps:

A root stump may be able to beretained and act as a spacemaintainer. However, even ifnot causing pain, a root stumpshould be removed if it iscausing deflection of thepermanent successor.

15


Documents

Technique notes atraumatic technique.€¦ · technique on open lesions in primary molars. Interim restorative treatments • Excavating caries The excavation technique shown below