a) E3 group from Australia- what are known risk factors? Do we really have a good understanding of the condition? What are current and future directions for research? How often are primary and non-molar/non-incisor teeth affected?
b) Classification of MIH- what are standardized and validated methods to classify the degree of MIH? How can clinicians contribute to epidemiologic data on the prevalence and severity of MIH? How do we differentiate MIH from other items on the differential diagnosis list?
c) Description of MIH in a micro and macrostructural level- what processes in maturation/secretion/calcification are affected, when are teeth hypocalficied (qualitative defect) and when are teeth hypoplastic (quantitative defect)? what contributes to post-eruptive enamel breakdown, and how rapidly does this occur?
a) Pain pathways for teeth affected by MIH- what are current concepts in dental pain, and why are teeth with MIH difficult to numb?
b) Review of articaine and why it might be a good adjunct for anesthesia- briefly review pharmacokinetics and pharmacology of articaine and when it should be used as an adjunct to blocks.
c) Does SDF help teeth affected by MIH? SMART technique? Does SDF slow lesion progression MIH? Does SDF reduce sensitivity in these teeth? Does the SMART technique hold the tooth over until a definitive restoration can be placed? What material should be used for the SMART technique (GI vs. RMGI)?
The objectives of this presentation are:
• To review of all relevant aspects related to the diagnosis of molar-incisor hypomineralisation (MIH);
• To provide an update on the etiology, prevalence and histopathology of MIH;
• To discuss the dental management and treatment options for the dentition affected by MIH;
• To review methods of effective local anesthesia for MIH teeth and to discuss the use of articaine in Pediatric Dentistry.
First permanent molars affected by caries, Molar Incisor Hypomineralization/Hypoplasia, and other pathologies present clinicians with the difficult decision to restore or extract teeth with guarded prognoses. This presentation will review the Clinical Guidelines from the Royal College of Surgeons, England, review clinical cases and describe protocols for timing balancing and compensating extractions (opposing and contralateral molars) to achieve favorable outcomes.
1. Describe reasons why a clinician may decide to extract rather than restore first permanent molars and review common risk-factors and clinical etiologies for non-restorable molars, including MIH.
2. Recognize the appropriate time to extract first permanent molars to allow mesial drift of the second permanent molar and establishment of a functional occlusion.
3. Identify when balancing extractions (extraction of contralateral molars) and compensating extractions (extraction of opposing molars) should be planned to achieve favorable orthodontic, esthetic, and functional outcomes based on evidence available.
To cover severely affected molars in general
a) Describe the span of GI materials- in this section, it would be helpful to review when GI and RMGI restorative materials can be used to temporarily restore teeth with MIH or advanced lesions? What are the benefits of GI vs. RMGI?
b) Bonding to affected dentin/enamel- How is the bond strength affected when bonding to teeth affected by MIH? Should we etch less or more?
c) When to use GI vs. composite, and what are the limitations? What guidelines should clinicians follow when deciding to restore with composite, full coverage, vs. GI materials? When preparing the tooth, should the margin be on unaffected enamel?
Participants will have an understanding of the clinical utilization of photopolymerized glass ionomer cements, dentin bonding adhesives and resin-based composites, including bioactive restorative materials and universal resins. Indications and contraindications for use of these restorative materials will be presented in accordance with standards of care and risk assessment.
1. SSCs for MIH molars: When should clinicians decide to place SSCs on severely affected molars? What is the longevity and effect on the periodontium?
2. When can we replace SSCs with porcelain/PFM/zirconia crowns? At what age can clinicians remove an SSC and replace with a PFM/Zirconia crown? How can digital dentistry be used in children? When should clinicians consider an onlay vs. full coverage restoration?
1. Recognize permanent molars that are better served with alternative restorations
2. Describe various clinical scenarios that impact treatment planning related to MIH
3. Determine the cost effectiveness of various treatment modalities related to MIH
When children have “white spots” on the incisors, how are they managed? How does the management differ between decalcification, hypomineralization, fluorosis, etc.?
a) Etch, bleach, seal technique for affected incisors
b) When to use icon, etch/seal, vs composite. Explain why ICON does not work well on many MIH lesions
c) What is the earliest age when we would consider a veneer or full coverage anterior tooth? Might touch on teeth affect by trauma. What is the longevity of strip crowns?
12:30-14:00, Dr. Vineet Dhar, Overview of New Evidence-based Pulp Therapy Guidelines for Primary Molars
Professor & Chair, Department of Orthodontics & Pediatric Dentistry,
Graduate Program Director, Pediatric Dentistry
University of Maryland School of Dentistry, Maryland, USA
Evidence-based clinical practice guidelines are informed by well-done systematic reviews and aim to represent the best available cumulative evidence. The development of clinical practice guidelines is both time and resource intensive as it must have the appropriate representation of certainty of evidence, balance of benefits and harms, patients’ values and preferences, resource utilization, and clinical expertise. Such guidelines are considered trustworthy and can be used by the clinicians to provide the highest quality patient-centered care in their practices. The AAPD published clinical practice guidelines on primary teeth vital pulp therapies in 2017 and on primary teeth non-vital pulp therapies in 2020. This session will explore the need for clinical practice guidelines from a clinician’s perspective and evaluate in-depth the basis and interpretation of key evidence-based recommendations for vital and non-vital pulp therapies in primary teeth including Lesion Sterilization and Tissue Repair (LSTR).
Upon completion, the participant will be able to understand the:
a) Indirect and direct pulp therapy- review fundamental of managing deep lesions in immature permanent teeth. When to do a direct pulp cap and with what material, and when to do an indirect pulp cap?
b) Update on bioactive materials- Please review the spectrum of bioactive materials available on the market (pro-root MTA, endosequence, NeoMTA putty, biodentine, etc.). When should we do a cervical pulpotomy on a permanent molar?
c) Regenerative endodontics/revascularization in non-vital immature perm teeth. Provide an overview of regenerative endodontics including case selection and brief description of the steps.
• To review the histopathology of dentinal caries and the defense response mechanism of the pulp to the carious process;
• To present the current challenges to decision-making in deep caries management;
Extractions vs Restorations
Review of Royal College of Surgeons guidelines.
a) Balancing and compensating extractions for non-restorable molars.
b) In what clinical situation should someone decide to extract more than one tooth for balancing and compensating?
c) This can review MIH as well as other molars that are severely affected (molar incisor root malformation, MIH, caries, etc.).
• In orthodontics, several teeth are considered almost sacrosanct and are seldom extracted. Many times, heroic efforts are devoted to restoring or position these teeth on the arch despite a high risk of morbidity and less than ideal prognosis;
• Permanent molars, canines are teeth that are less often extracted. Orthodontists usually do not hesitate to extract perfectly sound premolars and less frequently a lower incisor;
• Severely decayed molars are conserved despite their high cost of restoration, poor long-term prognosis and need for significant restorations;
• Maxillary impacted canines with poor positioning are brought into the arch with complex mechanics and significant morbidity, sometimes following the extraction of perfectly positioned premolars;
• In this lecture we will address the dilemma for the pediatric dentist of deciding if a tooth is better extracted if its prognosis is doubtful. Alternative of treatment will be presented with their own costs and benefits.
• How early should one intervene on an MIH molar?
• To extract or not to extract.
• Short, medium and long term considerations of MIH molars with current available prosthodontic options.
• Expected longevity of traditional prosthodontics versus implant prosthodontics.
• How many prosthetic revisions would one anticipate in a life span?
• Is endodontic therapy an expected outcome with multiple full coverage restorations over the life span of a tooth?
• Are eventual implant restorations an expected outcome?
This presentation will discuss the decision making in choosing to extract a tooth or save a tooth, including tooth restoration versus orthodontic care or implant and crown with associated costs.
Participants will understand treatment options associated with teeth exhibiting MH, decision making on choosing the appropriate treatment option and the costs associated with different treatments.