Atraumatic Restorative Treatment (ART) for tooth decay

Atraumatic Restorative Treatment (ART), is based on removing decalcified tooth tissue using only hand instruments and restoring the cavity with an adhesive filling material.
A minimally invasive approach to both prevent dental carious lesions and stop its further progression. 

Molar Incisor Hypomineralization

The term molar incisor hypomineralization (MIH) was introduced in 2001 to describe the clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFMs) that are associated frequently with affected incisors. The condition is attributed to disrupted ameloblastic function during the transitional and maturational stages of amelogenesis. This condition is recognized in various terms such as hypomineralized PFMs, idiopathic enamel hypomineralization , dysmineralized PFMs, nonfluoride hypomineralization and cheese molars.

Molar incisor hypomineralization

Epidemiology

The prevalence data for MIH are limited due to various diagnostic classifications. According to existing data the prevalence ranges from 4% to 25% across different populations. The number of hypomineralized PFMs in an individual can vary from 1 to 4, affecting particularly 2 or more molars including the contralateral tooth, where the teeth are moderately or severely affected. The risk of involvement of the permanent maxillary incisors appears to increase when more PFMs are affected.

Putative factors associated with disrupted amelogenesis of PFMs include systemic conditions and environmental insults influencing natal and early development specially during the child’s first 3 years.  The systemic conditions implicated to date include nutritional deficiencies, brain injury and neurologic defects, cystic fibro­sis, syndromes of epilepsy and dementia (Kohlschutter-Tonz syndrome), nephrotic syndrome, atopia, lead poisoning, repaired cleft lip and palate, radiation treatment, rubella embryopathy, epidermolysis bul­losa, ophthalmic conditions, celiac disease, and gastrointestinal disorders. Conditions common in the first 3 years, such as up­per respiratory diseases, asthma, otitis media, tonsillitis, chicken pox, measles, and rubella, are also known to be associated with MIH. Some studies suggest the association of Preterm birth with increased prevalence of enamel defects, including hypomineralization and hypo­plasia in the permanent dentition.

Clinical presentation and Diagnosis

Criteria for the diagnosis of demarcated opacities, post-eruption breakdown (PEB), atypical restorations, and extracted PFMs due to MIH were developed by Weerheijm et al. Dentitions with generalized opacities present on all teeth rather than limited to the PFMs and permanent incisors, are not considered to have MIH.

Four PFMs and 8 erupted permanent incisors are examined wet for demarcated opacities (white-cream or yellow-brown in color, of normal thickness with a smooth surface), post eruptive breakdown, and atypical restorations.

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     The opacities are usually limited to the incisal or cuspal one third of the crown, rarely involving the cervical one third.

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   Due to the unusual size and shape, restorations may not conform to typical caries patterns and frequently involve the cuspal or incisal one third of the crown.

·         Enamel opacities may occur adjacent to restoration margins.

Diagnostic Categories of MIH

·         Mild MIH

o   Demarcated opacities are in nonstress-bearing areas of the molar

o   No enamel loss from fracturing is present in opaque areas

o   There is no history of dental hypersensitivity

o   There are no caries associated with the affected enamel

o   Incisor involvement is usually mild if present

·         Moderate MIH

o   Atypical restorations can be present

o   Demarcated opacities are present on occlusal/incisal third of teeth without posteruptive enamel breakdown

o   Posteruptive enamel breakdown/caries are limited to 1 or 2 surfaces without cuspal involvement

o   Dental sensitivity is generally reported as normal

·         Severe MIH

o   Posteruptive enamel breakdown is present

o   There is a history of dental sensitivity

o   Caries is associated with the affected enamel

o   Crown destruction can advance to pulpal involvement

o   Defective atypical restoration

o   Aesthetic concerns are expressed by the patient or parent

Differential Diagnosis

Fluorosis

Amelogenesis imperfecta

Enamel hypoplasia

o   It can be differentiated from fluorosis as its opacities are demarcated, unlike the diffuse opacities that are typical of fluorosis. Fluorosis is caries resistant and MIH is caries prone and also fluorosis can be related to a period in which the fluoride intake was too high

o   Choosing between amelogenesis imperfecta (AI) and MIH: only in very severe MIH cases, the molars are equally affected and mimic the appearance of AI

o   In MIH, the appearance of the defects will be more asymmetrical and in AI, the molars may also appear taurodont on radiograph and there is often a family history.

Management

MIH’s clinical management is challenging due to:

1. The sensitivity and rapid development of dental caries in affected PFMs

2. The limited cooperation of a young child

3. Difficulty in achieving anesthesia

4. The repeated marginal breakdown of restorations.

Management of Molar incisor hypomineralization

Dental Fluorosis

Epidemiology

Dental fluorosis is a developmental disturbance of dental enamel caused by the consumption of excess fluoride during tooth development. It's caused by overexposure to fluoride during the first eight years of life more commonly, the time when most permanent teeth are being formed. 

Dental Fluorosis

Common sources of fluoride includes, toothpaste (if swallowed by young children), drinking water in fluoridated communities, beverages and food processed with fluoridated water, dietary prescription supplements that include fluoride (e.g., tablets or drops) and other professional dental products (e.g., mouth rinses, gels, and foams). Increases in the occurrence of mostly mild dental fluorosis were recognized as more sources of fluoride became available to prevent tooth decay. These sources include drinking water with fluoride, fluoride toothpastes (if swallowed by young children) and dietary prescription supplements in tablets or drops. Moderate-level chronic exposure (above 1.5 mg/litre of water - the WHO guideline value for fluoride in water) to drinking water is typically the most significant source. 

Dental fluorosis can occur among persons in all communities at different severities, even in those with a low natural concentration of fluoride in the drinking water. However fluoride in water is mostly of geological origin. Waters with high levels of fluoride content are mostly found at the foot of high mountains and in areas where the sea has made geological deposits. Known fluoride belts on land include: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan. In these areas fluorosis has been reported. Various studies from all over the world on the disease burden of different populations reveals different figures. But As of 2005 surveys conducted by the National Institute of Dental and Craniofacial Research in the USA between 1986 and 1987 and by the Center of Disease Control between 1999 and 2002 are the only national sources of data concerning the prevalence of dental fluorosis.

Data from the National Health and Nutrition Examination Survey, 1999-2004 and the 1986-1987 National Survey of Oral Health in U.S. School Children reveals that there were less than one-quarter of persons aged 6-49 in the United States had some form of dental fluorosis. The prevalence of dental fluorosis was higher in adolescents than in adults and highest among those aged 12-15. Adolescents aged 12-15 in 1999-2004 had a higher prevalence of dental fluorosis than adolescents aged 12-15 in 1986-1987. Another survey conducted in Indian subcontinent shows that fluorosis is an endemic disease prevalent in 20 states out of the 35 states and Union Territories of the Indian Republic.

Signs and symptoms

Symptoms of fluorosis range from tiny white specks or streaks that may be unnoticeable to dark brown stains and rough, pitted enamel that is difficult to clean. The severity of the condition depends on the dose (how much), duration (how long), and timing (when consumed) of fluoride intake. Since the 1930s, dentists have rated the severity of fluorosis using the following categories:

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• Questionable -The enamel shows slight changes ranging from a few white flecks to occasional white spots.
• Very mild      -Small opaque paper-white areas are scattered over less than 25% of the tooth surface.
• Mild               - White opaque areas on the surface are more extensive but still affect less than 50% of the surface.
• Moderate        -White opaque areas affect more than 50% of the enamel surface.
• Severe             -All enamel surfaces are affected. The teeth also have pitting that may be discrete or may run together.

Classification of Dental Fluorosis

Treatment options

Depending upon severity of the disease, treatment option varies. Micro/Macro abrasion, Bleaching, Composite restorations, Veneers, Full crowns are the main options available. These are described in detail in another article.

Disease prevention

Removal of excessive fluoride from drinking-water is difficult and expensive. The preferred option is to find a supply of safe drinking-water with safe fluoride levels. If you rely on well water or bottled water, your public health department or a local laboratory can analyze its fluoride content. Where access to safe water is already limited, de-fluoridation may be the only solution. Methods include: use of bone charcoal, contact precipitation, use of Nalgonda or activated alumina (Nalgonda is called after the town in South India, near Hyderabad, where the aluminium sulfate-based defluoridation was first set up at a water works level).

Health education regarding appropriate use of fluorides and parental vigilance is a key measure to prevent fluorosis. Keeping all fluoride-containing products such as toothpaste, mouth rinses, and supplements out of the reach of young children and monitoring your child’s use of fluoridated toothpaste are key facts. Only place a pea-sized amount of toothpaste on your child’s toothbrush. Also teach your child to spit out the toothpaste after brushing instead of swallowing it. To encourage spitting, avoid toothpastes containing flavors that children may be likely to swallow. Adult supervision of tooth brushing by children younger than 6 years of age and changes in recommendations for administration of fluoride supplements so that such supplements are not given to infants and more stringent criteria are applied for administration to children.

Teething in Infants

Teething is the phenomena accompanying growth of teeth through the gums. The effect of teething on infant health has been debated for at least 5000 years, and traditional beliefs on the issue have still not been entirely superseded by scientific findings. Sumerians believed teething and worm infestation were associated. Hindu writings, as well as work by Aristotle, Homer, Celsus, and others, describe associations between teething and illness. Many of these authors implicated tooth emergence in childhood mortality. The belief that teething led to childhood mortality, seizures, diarrhea, fever, or other serious conditions was criticized as early as the 17th century by Francois Ranchin. Yet in 1839, 5016 deaths in England and Wales were attributed to teething. Illingworth wrote in 1975 that “teething produces nothing but teeth.” However, as recently as 1979, parents and physicians were identifying teething as a cause of presenting symptoms in children admitted to the hospital. A medical evaluation of 50 of these children showed that in 48 cases the symptoms, ranging from upper respiratory infection to bacterial meningitis. Most medical professionals now agree that teething does not cause life-threatening illness, but they disagree about which symptoms may be associated with tooth eruption.

Teething in Infants

However several studies with different study designs has revealed symptoms believed to be associated with teething such as loss of appetite for solids and liquids, drooling, biting or chewing various objects, congestion or runny nose, cough, sleep disturbances, restlessness and irritability, rash, spitting up or vomiting, and diarrhea and fever or mild temperature elevation. Anyhow It is important to inform parents that none of these symptoms consistently and accurately predict when teething is about to occur and any of other organic disorders should be ruled out in infants with these symptoms.

The recommended intervention for teething is the use of cold items because the cold acts as an anesthetic for the gums. Refrigerated pacifiers, Spoons, Clean wet washcloths, Frozen bagels or bananas, refrigerated teething rings can be offered to the infants at this stage.Topical teething gels sold over-the-counter (OTC) are often used for teething but may carry serious risks, including local reactions, seizures with overdose, and methemoglobinemia. Benzocaine containing teething gels should not be used in infants or children under 2 years of age. If necessary, parents should be instructed on proper dosing of analgesic medications, such as acetaminophen or ibuprofen.