Original prevention remineralization resoration 2013

William Lieberman D.D.S., M.B.A
Pediatric Dentist

Dr. William H. Lieberman D.D.S., M.B.A.
• Private pediatric practice in New Jersey
• Past-President American Society of Dentistry for
Children
• Past Trustee, American Academy of Pediatric
Dentistry
• MBA, Healthcare
• Coordinator Dental Continuing
Education, Monmouth Medical Center
• Associate Clinical Professor at New York University
Brief Bio.

Prevention
Restoration
Remineralization

American Academy of Pediatrics
American Academy of Pediatric
Dentistry
Recommendation:
Dental home by age 1

ANTICIPATORY GUIDANCE –
What is it?
It is the process of providing practical, developmentally
appropriate health information about children to their parents
in anticipation of significant physical, emotional and
psychological milestones.
-Nowak and Casamassimo 1995

Counseling
Diet & Nutrition
Oral Hygiene
Habits

Airway Space
• The pediatric dentist can be the first to identify
airway structure issues.
• Learn how to incorporate this knowledge and
develop a medical/dental team approach for the
developing child

W-Loop
Dental Equilibration
Appliances :
eg. “W-loop”

Periodic exam
Why every 6 months?

© 3M ESPE 2010. All Rights Reserved
Ketac™
Ketac™ Nano
Quick Mix Capsule
Direct Restoratives Products

Cumulative Fluoride
Release
Oxman et .al. 2008 AADR Abstract #987
0
500
1000
1500
2000
2500
3000
3500
1 7 14 28 120 180 360
days
FluorideReleaseppmf/g
Ketac Nano Fuji II LC Vitremer Fuji IX

Recaldent
Novamin
Pro-Argin
Remineralizing
Agents

First Visit
Exam
Counseling
Varnish

Second Visit
ITR (Interim Therapuetic Resortation)
Fluoride Varnish
Tooth Mousse

Third Visit
Fluoride Varnish
Counsel
Repair

ITS
Interim Therapeutic Strip Crowns

Pulp Therapy for Primary
Teeth

Successful Pulp Therapy requires:
• Correct Diagnosis
• Vital
• Non-vital
• Restoration
• Microleakage

Characteristics of Reported Pain
Provoked : thermal, chemical, mechanical
• indicates dentin sensitivity, pulp in transitional stage
• usually acute inflammation and reversible
Spontaneous
• throbbing, constant
• indicates advanced pulp damage
• pulp usually non-treatable
• irreversible pulpitis or necrosis
• often nocturnal

Radiographic Examination
Internal resorption
• once internal resorption has become advanced to
be seen radiographically there is usually a
perforation of the root by the resorptive process
Pathologic bone and root resorption
• Indicative of advanced pulp degeneration. The
pulp tissue may remain vital even with such
advanced degenerative changes.

Medicaments for Pulpotomy
Formocresol
Ferric
Sulfate
Mineral Trioxide
Aggregate (MTA)

Vitapex
Premixed Calcium Hydroxide

IPT Technique
• Gross caries removal
• Walls extended to sound tooth structure
• Infected dentin removed
• Affected dentin remaining
• Should have 1mm sound dentin over remaining pulp
• Base over remaining dentin
• Final restoration
• Must have good marginal integrity
• Recall for evaluation

IPT Protocol
• Local anesthesia and rubber dam placement
• Excavation of infected dentin
• Caries detector (Sable Seek® from Ultradent) utilized
• Cavity photographed
• Placement of 2.0% chlorhexidine gluconate viscous
solution, Consepsis V® (Ultradent Products, Inc) for 60
seconds
• Placement of a resin-modified glass ionomer (Fuji II-LC®
GC America) on the preparation floor
• Final restoration placement: internal or full coverage
• Final photograph
• Recall 3, 6 and 12 months

Radiographic findings of primary first molar
post-treatment
6 months post-treatment
12 months post-treatment

Findings:
• 3 month recall 100% teeth were WNL
• 6 month follow-up 93% teeth were WNL
• Failure of Class II composite and one SSC restoration
• 12 month recall all remaining teeth were WNL
ProspectiveIPTinPrimaryMolarsusingRMGIand2%
CHX:A 12monthfollow-up

Restorative Materials
Composites
Flowable
RMGI
Giomers
Crowns

Local Anesthesia for
Patients
Dr. William H. Lieberman D.D.S., M.B.A.
Pediatric

1975-2013
Then & Now
• Syringes • The Wand / STA - Single Tooth Anesthesia
System Instrument

Drug choice and Volume
4% Articaine HCL
• Adult: ½ cartridge
• Child: ¼ cartridge
• Preferred Vasoconstrictor Concentration
• 1:100,000 epinephrine
2% Lidocaine HCL
• Adult: ¾ cartridge
• Child: ½ cartridge
• Preferred vasoconstrictor concentration
• 1:100,000 epinephrine

Prevalence of Dental Fear?
Agras, et al. 1979
20%

Technology ?1853 1904 2010
150+ years

Computer-Controlled
Local Anesthetic
Delivery System
“New Innovation”
“C-CLAD”
1997

1997 – 1st
Generation
2007 – 3rd
Generation
Computer Controlled Local
Anesthetic Delivery System

Disruptive Technology
•An innovation that alters a product or
service in ways the market does not
expect

Allows you to
do something you
can’t do any other way!

Dynamic Pressure Sensing
Technology - DPS™
• Monitors “Exit-Pressure”
• Real-Time, continuous
information
• Visual and audible feedback
• System control: “Exit-Pressure”

No
Feedback
FPO
Total
Feedback

Lesson 1
Set Up and Basic
Operation

Step - 1
FRONT
• Attach Foot Control
• Tighten Securely
BACK
• Attach Power Cord
• Turn Power Switch On
• Wait 5 seconds for STA to
Self-calibrate

Step - 2
ANESTHETIC CARTRIDGE
• Insert cartridge into holder
• Press firmly until spike punctures the diaphragm

Step - 3
Wand Handpiece & Needle
• Attach Luer-Lock needle to
handpiece, if necessary
• Tighten securely
• Place needle and cap into holder
on either side of STA

Step - 3
Shorten length of
Wand Handpiece
• Remove tubing handpiece
• Shorten by “breaking” the length
of the handle
• Mark the bevel

Step - 4
• Insert wings of holder
into top of STA
• Turn counter-clockwise
¼ turn
• STA activates and purges
handpiece of air
• Lights are activated
Insertion of Cartridge Holder

Step - 4b
• Turn clockwise ¼ turn • Push cartridge out using
finger slots at top of cartridge
holder
• Remove cartridge and
continue
Removal of Cartridge Holder

• The Training Mode provides
an audible explanation of the
various functions of the STA
• Allows one to become familiar
with operating the STA
• Enable Training Mode by
pressing and holding the
“Hold to Train” button for 4
seconds
Easy Learn: Training Mode
Step - 5

Lesson 2: Performing the
STA-Intra-ligamentary Injection
Learn the Injection of
Your Choice
Lesson 3: Performing the
AMSA – (Palatal) Injection

Lesson 2
Tools needed to perform
STA-IL Injection
• What you need to perform this injection:
• Bonded - 30-g ½ inch STA-Wand® Handpiece
• The STA drive-unit set to “STA” mode
• Activate Training Mode feature (optional)

Lesson 2
Performing STA-IL
Injection
• What you need to learn:
• How to use Cruise-control feature
• Understand how DPS® works
• How to use STA aspiration to prevent back-spray of anesthetic into patients
mouth

Performing
STA-Intra-ligamentary
Injection

Easy Learn: Cruise Control
• What is the Cruise Control
feature:
• The feature allows you to deliver anesthetic
solution without the need of continuously
depressing the foot pedal, it’s analogous to
cruise-control in your car in which you release
the accelerator and continue to drive.
• How do you activate:
1. Start injection by depressing pedal
2. After 3 seconds voice prompt will
say “Cruise”
3. Immediately release foot off pedal
to remain in cruise mode
• How do you de-activate:
• Tap foot-control pedal to stop
Step - 1

Easy Learn: STA-IL Insertion Site
• Area effected:
• Single Tooth Anesthesia
• Injection site:
1. Start on distal
2. Bend needle, if necessary, to gain
access
3. It is best to maintain a direct view
of the needle and it’s entrance to
the sulcus at all times
4. It is important for the shaft of the
needle to be parallel with the
surface of the root
Step - 2

You need a slight bend to the needle to allow proper access.

NOTE:Youcannotaccessthedistalofthelowermolars
properlywithoutbendingtheneedleslightly.
Incorrect Correct
Unbent needle Bent needle
(allows proper angle and access to PDL)

• Importanttomaintaindirectvisionofproperneedleangle
andneedleentranceintothesulcuswhenusingeither
approach
• Distal-buccal requires needle to be bent as well
Buccal Approach

Mesial Approach
Incorrect needle
angle and entrance
Correct
• Proper angle and entrance can be achieved with bent or straight needle
Incorrect

 Objective of Insertion:
1. Needle tip to entrance of PDL
 Angle of Insertion:
1. 30 to 45 degrees
2. Bend needle, if necessary
3. Direct vision of needle
4. Needle shaft parallel to root
 Movement of Insertion:
1. Very SLOWLY advance needle
producing Anesthetic Pathway
2. Needle is inserted like a
“Periodontal Probe”, gently
Easy Learn: Needle Insertion
Step - 3
30º

Easy Learn: Dynamic Pressure Sensing
• What is the DPS feature:
• This feature provides real-time audible and visual
feedback to indicate when the needle is properly
positioned when performing the STA-Intra-
ligamentary (PDL) injection.
• How to use:
1. In STA-Mode only
2. Start injection
3. Insert needle into “assumed” correct
PDL injection location
4. Wait approximately 10-15 seconds in
“assumed” correct location
5. Listen & Watch, “ascending tone” &
Increase of Pressure Scale through
“orange” LED zone
6. Maintaining the High “orange” or the
“green” LED zone throughout confirms
proper needle location
Step - 4

Easy Learn: DPS®
technology
Trouble Shooting:
• Problem:
Pressure not building:
1. Insufficient hand pressure on
STA/Wand handpiece
2. Did not wait 10 -15 seconds to allow
pressure to build
3. Incorrect needle position
Over-Pressure Alert:
1. Excessive hand pressure on
STA/Wand handpiece
2. Blocked needle tip with excessive
hand pressure into PDL tissue
3. Incorrect needle position
Step - 5

AMSA Injection
• A new technique that enables us to anesthetize a maxillary
quadrant in the primary dentition with one injection.

Lesson 3
Tools needed to perform
AMSA - Injection
• 30-g ½ inch – Bonded STA-Wand® Handpiece
• Cotton-applicator with wooden-handle required
• The STA drive-unit set to “STA” mode

Lesson 3
How to Perform AMSA-
Injection
• What you need to Learn:
• How to perform Pre-Puncture Technique
• How to perform Anesthetic Pathway Technique
• How to use STA-aspiration to prevent back-spray of anesthetic
into patients mouth

Easy Learn: AMSA Insertion Site
• Area effected:
• The AMSA can produce pulpal anesthesia
from the Central Incisor to the 2nd Premolar
and the associated hard and soft palatal
tissues.
• Injection site:
1. Imagine a line located between
the 1st and 2nd Premolar
2. Mid-way along an imaginary line
from the palatal suture to the free
gingival margin
3. Approach this site with the hand-
piece from the contra-lateral
premolars
 Bisect premolars
 Midway between the free
gingival margin and
mid-palatine suture
Step - 1

Easy Learn: AMSA Insertion Site
• Injection site:
1. Imagine a line located between
the 1st and 2nd Premolar
2. Mid-way along an imaginary line
from the palatal suture to the free
gingival margin
3. Approach this site with the hand-
piece from the contra-lateral
premolars
Step - 1

Clinical Technique: AMSA
Injection

Lesson 4
Performing P-ASA Injection
• How to perform Pre-Puncture Technique
• How to use STA-aspiration to prevent back-spray of anesthetic
into patients mouth

Clinical Technique: P-ASA Injection

Easy Learn: P-ASA Insertion Site
• Area effected:
• The P-ASA can produce pulpal
anesthesia of the Central and
Lateral Incisors and the associated
hard and soft palatal tissues
• Injection site:
1. Entry point is the incisive groove
surrounding the incisive papilla
2. Final needle tip position is within
the incisive canal
Step - 1

Easy Learn: Anesthetic Pathway
• What is the Pre-Puncture
technique:
• The technique allows you to penetrate and
advance the needle through the palatal
gingiva with minimal discomfort to the
patient
• How to perform:
1. Place bevel against surface with
cotton-applicator on-top
2. Wait 8 seconds- then rotate and
penetrate surface 1 - 2 mm
3. Advancement Pace: 1 - 2 mm
then wait 4 seconds to allow
anesthetic to proceed needle
4. Advance needle until bevel
contacts surface of bone
Step - 2

Clinical Technique: P-ASA
Injection

Lesson 5
Tools needed to perform IA
Block Injection
• Smaller Children: 30-g 1 inch – Bonded STA-Wand® Handpiece
• Adolescents : 27-g 1 ¼ inch – Bonded STA-Wand® Handpiece
• Normal Mode

Lesson 5
Performing IA Block
Injection
• How to change to Normal Mode
• How to use Bi-Rotational Insertion Technique
• How to use STA-aspiration
• How to use 2 speed operation

Easy Learn: Bi-rotation Insertion
• Bi-rotation Insertion technique:
• This technique allows you to minimize needle
deflection during insertion.
• How to perform:
• Rotate needle in a back-n-forth fashion

Rotational
Insertion
Linear
Insertion
Deflection
X X
Linear Rotational
Insertion Techniques

Easy Learn: 2-Speed Operation
Step - 1
1
2
• Using “Normal” mode 2-
speed operation:
• You can more effectively and efficiently
perform the IA Block using the 2-speeds
How to use:
1. Depressing the foot control lightly
allows you to start the injection using
the ControFlo (slower) flow rate – Use
for the first ¼ cartridge of IA Block
2. Depressing the foot control all the way
down allows the second, more rapid
rate to administer the remaining volume
of anesthetic

Easy Learn: Aspiration
Step - 2
1
2
3
• Using Aspiration to prevent
intravascular needle
placement:
• You can prevent needle placement into a vessel
by use of aspiration
How to use:
• After completion of needle placement:
1. Press and then release foot-control
pedal to activate aspiration, which is six
beeps for the complete cycle
2. If you see blood in the needle hub, re-
position needle and re-aspirate until
negative observation

• Anesthetic Pathway
technique:
• This technique allows you to penetrate and
advance the needle through the mucosa and
soft-tissues with minimal discomfort to the
patient.
• How to perform:
1. Penetrate mucosa
2. Advancement Pace: 1- 2 mm
3. Advance needle until contact
against surface of bone

Lesson 7
Tools needed to Perform
Supraperiosteal/Buccal
Infiltration Injection
• 30-g 1-inch Bonded STA-Wand® Handpiece
• Normal Mode

Lesson 7
Performing Supraperiosteal/
Buccal Infiltration Injection
• How to change to Normal Mode
• How to use STA-aspiration
• How to use 2 speed operation

• Anesthetic Pathway
technique:
• The technique allows you to penetrate and
advance the needle through the mucosa and
soft-tissues with minimal discomfort to the
patient.
• How to perform:
1. Penetrate mucosa
2. Advancement Pace: 1 - 2 mm
3. Advance needle until contact
against surface of bone

Aspiration
After purging, STA
defaults to Aspiration
ON
If not needed, Aspiration can
be turned OFF, by pressing
Aspirate button

Cartridge Volume
• LED lights indicate
amount of anesthetic
solution remaining
• STA “bongs” once when
¼ cartridge is
expressed, twice when ½
is expressed, and three
times when ¾ is used

Sound Volume Control
To Change Audible
Volume:
• Press up arrow to increase
volume
• Press down arrow to
decrease volume

Modes of operation:
STA, Normal, Turbo
“Select” button change
• A - STA Mode – 1 speed
ControlFlo only
DPS® (Dynamic Pressure
Sensing)
• B - Normal Mode – 2 speed
ControlFlo and RapidFlo
• C - Turbo Mode - 3 speed
ControlFlo, RapidFlo, and
TurboFlo
A
B C

Foot Control and Mode Selections:
• Depress Pedal Slightly
• ControlFlo Speed
• Used for Palatal and PDL injections
exclusively
• Start of all injections during the first
¼ cartridge
• Depress Pedal Moderately
• RapidFlo Speed
• Infiltration & Mandibular Block
• After first ¼ cartridge only
• Depress Pedal Firmly
• TurboFlo Speed
• After first ½ cartridge only

DPS® - Dynamic Pressure Sensing
• Informs the Dentist of Correct Injection Site (PDL Space) with
Ascending Lights and Sounds
• Informs the Dentist if the Needle has Left the Correct Site
• Informs the Dentist if the Needle has been Blocked
• All Feedback Information in Real Time

STA-IntraligamentaryInjection
Technique: DPS - Dynamic Pressure
Sensing
• Hold needle steadily in place with minimal
pressure for approximately 15 seconds
• Ascending tones and lights will indicate the
needle is in the correct injection site, the
periodontal ligament space
• If ascending tones and lights are not initiated
after 15 seconds, move needle slightly until
the correct position is attained and lights and
tones are seen and heard

THE ROLE OF cclad
IN
Pediatric dentistry

Behavioral Management
• CCLAD technology has improved the overall acceptance of the anesthetic
injection in the pediatric population leading to less disruptive behavior.

References
• Lieberman, William H. Clinical Session: The Wand. Pediatric
Dent. 1999;21:2
• Allen KD, Kotil D, Larzelere RE, Hutfless S, Beiraghi S.
Comparison of a computerized anesthesia device with a
traditional syringe in preschool children. Pediatric Dent. 2002
Jul-Aug;24(4): 315-20

Pediatric
Restorative Dentistry

Bi-Lateral
Restorative Dentistry
Efficient

Dr. Bill’s Helpful Tips
•Needle choice
o 30 gauge for all
o1” for older children mandibular blocks
o ¾” for infiltration and blocks in younger children
o ½” for STA (periodontal ligament injection)

• Break the Wand for any injection to better
“cup” the needle
• Mark the bevel with a permanent marker
• Bend the needle with caution, as needed, for a
better angle

• Instrument location - LED’s should be clearly
visible to operator & within reach
• Start instrument prior to injection to avoid
startling the patient
• Use cruise control- NEVER turbo w/ pediatric
patient

• Avoid dripping the anesthetic in the mouth - the
bitter taste is the easiest way to lose a compliant
patient
• Develop a consistent pattern of injection site
(distolingual is best due to anatomy if
manageable)

•Rule of 2’s for STA:
o20 seconds MAXIMUM time to be in one
location
o2 minute window to begin procedure
o20 minutes to complete treatment
• Watch the videos on the website…very helpful!
www.STAis4U.com

Summary
 Audible & visible assurance of pulpal anesthesia
 Painless- minimizes disruptive behavior
 Immediate onset of anesthesia
o no delay is important for a child’s short attention span
o saves chair time
 Multiple quadrants at the same visit
 No soft tissue numbness - no risk of lip biting

Original prevention remineralization resoration 2013

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