Download - SMART-Malaysia 0415 Part 1
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SMART Preventive Restoration for Caries in
Primary Teeth
Prathip Phantumvanit
Thammasat University, Thailand
Former Vice-Chair, Public Health Committee, FDI
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Concept – hy !"#$T% hat !"#$T% Caries removal – Ho& clean%
'lass ionomer – hich material% Practicability – here settin(% hen
!"#$T% Procedure – Ho& !"#$T% #cceptability – ho bene)t%
Overview
Prathip Phantumvanit !"#$T*+ ./.0 *
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%caries
dmft dt mt ft
1apan 2*3 342 +34/ + 0.95
"alaysia 523 635 63 + 0.2
Thailand(5)
78.5 4.37 3.98 0.13 0.26
"yanmar 4/ 2362 230 + 0.!
Vietnam 423/ 32 3+5 +36 0.02
7ao PD$ 4430 5,/ 53/* +3+6 0
Cambodia /63 /3+ 43/ +3 0
./.0Prathip Phantumvanit !"#$T
*+
"enta# Caries Stat$s in yr&o#d
6
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Severe 'ar#y Chi#dhood Caries(s'CC)
De)nition8
◦ $ampant caries in
primary dentitionespecially in theupper anterior teeth,
as ear#y as in
todd#ers andyo$n* chi#dren,
Prathip Phantumvanit !"#$T *+./.0 2
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7ess important due to e9pected e9:oliation o:primary teeth
!everity o: carious lesions due to non-earlydetection and care
Dental :ear in children due to sound and &ater
:rom aeroter drillin( machine ; in
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Concept – hy !"#$T% hat !"#$T% Caries removal – Ho& clean%
'lass ionomer – hich material% Practicability – here settin(% hen
!"#$T% Procedure – Ho& !"#$T% #cceptability – ho bene)t%
Overview
Prathip Phantumvanit !"#$T*+ ./.0 0
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Minimum instrument only hand instrument
Minimum procedure Partial caries removal; )lled &ith 'lass
ionomerMinimum pain no anesthetic in
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ART SMART,"eve#o/ment
ART SMART1987 2012(25 years later)
use only hand
instruments to removecaries
use hand instruments
but onlypartial cariesremoval
filled with self-cure
powder-liquid hand-
mixed glass ionomer
filled with self-cure
capsulated glass
ionomer
aimed at permanent
molar
aimed atprimary
dentition
target at primaryschool children target atpre-schoolchildrenPrathip Phantumvanit !"#$T
*+ ./.0 4
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!"#$T phone, !"#$T car, !"#$T TV, etc3 !"#$T preventive dental restoration –
!impli)ed "odi)ed #traumatic $estorative
Techni=ue Phantumvanit P 2012 IJOH
* main components o: !"#$T
◦ partial caries removal◦ capsulated (lass ionomer cement
Prathip Phantumvanit !"#$T*+
SMART /reventiverestoration
./.0 /
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Concept – hy !"#$T% hat !"#$T% Caries remova# 1ow c#ean
'lass ionomer – hich material% Practicability – here settin(% hen
!"#$T% Procedure – Ho& !"#$T% #cceptability – ho bene)t%
Overview
Prathip Phantumvanit !"#$T*+ ./.0 +
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'ven certain amo$nt of softened
and deminera#ied dentine can3e safe#y #eft $nder *#assionomer restorations, providedthe mar(in is completely sealed
around its :ull circum:erence3 Kidd et al 2004
1ow c#ean m$st a cavity 3e
3efore restoration
Prathip Phantumvanit !"#$T*+ ./.0
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Focus o: microbial spread starts to appear alon(the D>1, underminin( the enamel3
The 3acteria# /ro4#e act$a##y decreaseda#on* the "'3
hen the deminerali?ed enamel is removed
alon( the D>1, so$nd ename# is a//arent withno *a/ and no /resence of 3acteria f$rthero$t a#on* the "'3
Kidd !"# J$%&t$n'ehal * + ei,ht$n - 1993
Cario$s #esion at "&'
6$nction
Prathip Phantumvanit !"#$T*+ ./.0 *
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Remove the one of3acteria# invasionand destr$ction ofcario$s dentine withs/oon e7cavator
"a@e circ$#arscoo/in* movementfrom "' downwards
Protect the pulp at theAoor o: deep cavities
circularmotion
Action of cario$s dentineremova#
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. O$ter #ayer ofirreversi3#e denat$redand deminera#ised8infected dentine3
*-2 Combine to :orm the inner
layer o: reversi3#ydeminera#ised, aBecteddentine
6 Transparent layer o: cariousdentine
2 !ub-transparent layer o:carious dentine
Harder layer o: sounddentine
0 !o:ter layer o: sounddentine adnamel>D1 !ound
Dentin
e
Pulp
Banerjee et al. 2000;
To beremoved
Histolo(ic ?ones o: cariousdentine in an active, appro9imal
lesion
Prathip Phantumvanit !"#$T *+
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Pro*ression of occ#$sa# cario$s#esion(Thylstrup & Fejerskov, 196!
one o: bacterialinvasion and
destruction in:ecteddentineE
one o:deminerali?ation
aBected dentineE!clerotic ?onereminerali?ationE
$eactive dentine
reparative dentineE
./.0Prathip Phantumvanit !"#$T
*+
2
:
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;y /hysica##y removin* the hi*h#yinfected tiss$e itse#f ,
;y restrictin* the n$trient s$//#y tothe remainin* 3acteria in the dentine,
;y $sin* 3acteriostatic restorative
materia#s (e.*. *#ass ionomer cement)to inactivate the remainin* micro3es3
ane/ee !# at&$n T and Kidd !"# 2000
Cario$s /rocess in dentine can
3e arrested,
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Ten articles, si9 studies, three $CTs, one &ith a :ollo&-up to + years, provide evidence supportin( thepractice o: #eavin* 3ehind infected dentine3
Cario(enic bacteria, once iso#ated from theirso$rce of n$trition by a restoration o: sucientinte(rity, either remain dormant or die and thuspose no ris@ to the health o: the dentition3
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;acteria# co$nts consistent#y dec#inedwhen com/ared to the 3ase#ine
Red$ced n$m3er of 3acteria sea#ed inthe minima# intervention a//roach didnot interfere with restoration s$rviva#
;acteria were red$ced or e#iminated 3y
cavity sea#in*, bene)cial chan(es in thelesion environment, :avorable conditions :orthe healin( process in primary teeth
amie -* et al 2007
Micro3io#o*ica# as/ects of thedentine #esions 3y /artia#
caries remova#
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Partial caries removal in symptomless,primary or permanent teeth reduces theris@ o: pulp e9posure3 Go detriment to thepatient in terms o: pulpal symptoms3!tudies that not re-entered do not reportadverse conse=uences3
iette& -J# Kidd !"# Inne& + la&$n J 2006%ohrane
Meta&ana#ysis of /artia# caries
remova#
Prathip Phantumvanit !"#$T*+ ./.0 /
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ased on 602 screened articles, + studiesrepresentin( ,*5 patients &ere included3
"eta-analysis sho&ed ris@ reduction :or bothpulpal e9posure and pulpal symptoms :or
teeth treated &ith or * steps incompletee9carvation
ased on revie& studies, incomplete cariesremoval seems advanta(es to complete
e9carvation, especially in pro9imity to thepulp3
(*h:endi&e et al# 2013 J- 92; 30
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!tep&ise caries removal resulted in a 0 reductionin incidence o: pulp e9posure compared to completecaries removal, the mean incidence o: pulpe9posure &as 6235 in the complete caries removal
(roup and 32 in the step&ise (roups3
Partial caries removal reduced incidence o: pulpe9posure by 55 compared to complete cariesremoval, the mean incidence o: pulp e9posure &as
*3/ in the complete caries removal (roups and in the partial caries removal (roups3
O/erative caries mana*ement in ad$#ts andchi#dren (%ohrane 201'!
Prathip Phantumvanit !"#$T*+ ./.0 *
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Caries remova# Traditional Operative
Dentistry
Current Biological-
approached Cariology
eliminate softened
infected carious dentine,
demineralized dentineand sclerotic dentine
conservative (partial)
caries removalof
infected soft dentine, onlyat DEJ
apply some agent
(Ca(OH)2) to protect pulp
defense mechanism of
pulp as reparative
dentine
extend removal of
(overhang) enamel and
dentine as cavityrearation for
conservation of enamel
and dentine for adhesive
restorative and preventivematerialPrathip Phantumvanit !"#$T
*+ ./.0 **
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Concept – hy !"#$T% hat !"#$T% Caries removal – Ho& clean%
=#ass ionomer -hich materia# Practicability – here settin(% hen
!"#$T% Procedure – Ho& !"#$T%
#cceptability – ho bene)t%
Overview
Prathip Phantumvanit !"#$T*+ ./.0 *6
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Strontium Fluoro Alumino Silicate glass
+ polyacrylic acid
Sr-Al-Ca-polyacrylate chain K F-
(powder) (liquid) (matrix) (release)
chemical bond &ithdentin and enamel
e9chan(e
reminerali?ation
Chemical reaction of Glass ionomer
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Prathip Phantumvanit !"#$T*+ ./.0 *
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3 riva sel: cure,HV
*3 riva silver63 riva li(ht cure
23 riva lutin(
3riva lutin( plus03 riva protect
S"< *#ass
ionomers
Prathip Phantumvanit !"#$T *+./.0 *0
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3 sel: cure Fu9traE
*3 silver
63 li(ht cure Fu
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Polyacrylic acid displaces phosphate andcalcium ions :rom the tooth and ta@en upinto the 'I ad
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=#ass ionomer cement
'lass ionomer cements (ained popularitythrou(h their a3i#ity to 3ond direct#y toename# and dentine and theircontin$o$s @$oride re#eased3
Ge&er versions o: chemically curin( (lassionomers such as Fu
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>9cellent Auoride release onds to enamel, dentin ; metals 'reat mar(inal inte(rity F- rechar(eable Go :ree monomers Can bul@ )ll >9cellent biocompatibility $adiopa=ue
Advanta*es of conventiona# =#assionomer
Prathip Phantumvanit !"#$T*+ ./.0 6+
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=reat mar*ina# ada/tation
Nsel:-cure (lass ionomerbases &ere more eBective inreducin( microlea@a(e in
both the occlusal andpro9imal cavo sur:aces thana Ao&able resinO
Duon( T et al, Tu:ts University, Ge&
rleans I#D$ *++5, #btractQ+600Prathip Phantumvanit !"#$T *+./.0 6
Cario$s #esions at mar*ins
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Cario$s #esions at mar*insof restorations, systematic
review 'lass ionomer cement restored cavitiessho& less recurrent carious lesions oncavity mar(ins than cavities &ith amal(am
"ienaut&h et al u$ean J Paediati -ent 2009
'lass ionomer cement has a hi(her caries
preventive eBect than amal(am :or
restorations in permanent teeth, nodiBerent &as :ound in primary dentition3 "ienaut&h + =en,$al " e& $te& 2011# 4;58
Prathip Phantumvanit !"#$T*+ ./.0 6*
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Com/arative /ro/erties ofrestorative materia#s
Materia#s Tensi#estren*th(MPa)
Com/ressivestren*th(MPa)
#e7$ra#stren*th(MPa)
#mal(am 2-0 6+-*+ +-+
Compositeresin
6-0+ *+-24+ ++-2
'lass ionomerHi(h
stren(thE
2-*6 dayE *2+-*0 5daysE
*-6 dayE
Dentine 65-* *4-624 *05
>namel + *5+-22+ na
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0
20
40
60
80
100
120
1 10 100
Immersed time / day
V i c k e r s
h a r d n
e s s
n u m
b e
"aturation in saliva
Physical properties
!aliva has theremar@able eBect o:increasin( sur:ace
hardness o: Fu
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!tudy by8
"cIntyre 1" et al, Ion e9chan(e bet&een $iva
!el: Cure 'IC and deminerali?ed dentine, Uni
#delaide, risbane I#D$ *++0
Proven ionice7chan*e
Prathip Phantumvanit !"#$T *+./.0 6
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#$oride re#ease
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Fluorie release )rom *lass+onomer
Fluoride Internal to cavity &all acteriostatic $eminerali?ation
>9ternal to the oralenvironment $eleased into tooth
tissues and saliva 'I restorations and
sealants ta@e upAuoride rechar(eE
Prathip Phantumvanit !"#$T *+./.0 65
#
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=#ass
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Ca/s$#ated *#ass ionomer
Prathip Phantumvanit !"#$T*+ ./.0 6/
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or@in( time
or@in( time
aitin( Time
be:ore )nishin(
aitin( Time
be:ore )nishin(
+ 0+ ,*+ ,4+DsecE
0 secfaster
X!"# %ast settin& ti'e
Final )nishin( can start a:ter
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$e(ular ; :ast settin(capsules
$e(ular settin(po&der.li=uid
Settin* times
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Re*$#ar set
"i9in( time8 0 secor@in( time8 min :0 sec
Initial settin( time8 : min 0
secFinal )nishin( time8 min
Ca/s$#e worBin* times
Prathip Phantumvanit !"#$T *+./.0 2*
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$iva !C8 0.5
mFu
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# -yr evaluation o: the success rate o: l I+ II e&t$ati$n& $> the ima% m$la&e&t$ed :ith hih-visosity *+ :a& 94? Silma? S et al *++0E
#:ter yr, the overall &uvival e&t$ati$n&$> 6I :a& 95? >$ l I and 82? >$ l IIe&t$ati$n& @ impli)e, Moi/e #T orM#T (Ph$n,han%udh ! et al 2012 $m
-ent Health)
=< in /rimary teethrestorations
Prathip Phantumvanit !"#$T*+ ./.0 22
C#inica# and Micro3io#o*ica#
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C#inica# and Micro3io#o*ica#eva#$ation of caries remova#methods
Prathip Phantumvanit !"#$T*+ ./.0 2
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reD$encies of MSE;ETFC for cariesremova# 3efore and after 2 months
"' (nG2) ART (nG2) ;+R (nG2)CFU "!.7.TVC "!.7.TVC "!.7.TVC
e:ore #:ter *mo
e:ore #:ter* mo
e:ore #:ter* mo
GD +.*.+ *.*.+ +.6.+ *.*.+ +.6.+ /.*.+
+-++ +..+ +.+.+ +.6.+ +.+.+ +..+ 6.+.2
+-+++ .+.+ +.+.+ +.+.+ +.+.+ +.*.+ +.+.*
++-++++ .+.+ +.+. +.*.+ +.+.+ +.6.+ +.+.2
+++-+++++ +.. +.+. ..+ +.+.* *.*.+ +.+.+
+++++ +.2. +.+.+ 5.6.* +.+.+ +..* +.+.*
P$n,han%uth !# *$n,ai&an = + Phantumvanit P#Prathip Phantumvanit !"#$T
*+ ./.0 20
C$m$#ative s$rviva# rates (%) for C#ass
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C$m$#ative s$rviva# rates (%) for C#ass< H
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Caries chan*es in cariesremova# methods8 after 2
monthsCariesremova#
% Caries/ro*ressio
n
% Cariesre*ression
%+nchan*ed
caries
>D1n45 *36 5302 4+3++
#$Tn/+
*326 53+5 4+324
U$n /0
*364 2350 /*34
P$n,han%uth !# *$n,ai&an = + Phantumvanit P# 2009
Prathip Phantumvanit !"#$T*+ ./.0 24
Radio*ra/hic chan*es after
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Radio*ra/hic chan*es after2 mo
Carious lesionbe:ore restoration
#:ter restoration
&ith >D1 cariesremoval sho&edcaries re(ression
Prathip Phantumvanit !"#$T *+./.0 2/
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Concept – hy !"#$T% hat !"#$T% Caries removal – Ho& clean%
'lass ionomer – hich material% Practicability – here settin(% hen
!"#$T% Procedure – Ho& !"#$T%
#cceptability – ho bene)t%
Overview