Many individuals develop dental anxiety during childhood despite conscientious efforts by dental professionals to make young patients more comfortable during routine oral hygiene appointments1 and regardless of parental encouragement to practice daily oral hygiene habits (eg, twice-daily toothbrushing using fluoride toothpaste).2 Although more frequent dental visits have been associated with less dental phobia, the types of dental treatment received during those appointments (eg, fillings, extractions) have been indirectly linked with childhood dental anxiety.3 In this article, a clinical case exemplifying dealing with a young patient with severe dental anxiety will be discussed.
Research has shown that children who have undergone orthodontic treatment and invasive dental treatment experience dental fear more often than children who have undergone invasive treatment only or no treatment at all.4 Interestingly, the research demonstrates that a child’s familiarity with dentistry through orthodontics does not decrease their dental fear.4
Unfortunately, a child’s dental anxiety and resulting poor dental hygiene can lead to caries and other oral health problems.1 In some cases, the caries may develop on tooth surfaces with pits and fissures, and sealants have proven effective in managing and preventing lesions in these areas.5 However, due to their mineral-releasing effects, glass ionomers have been effective in remineralizing and preventing caries on adjacent tooth surfaces, on cavosurface margins, and interproximally.6
|Figure 1. Preoperative view following removal of fixed orthodontic appliances.|
|Figure 2. The pre-op radiograph confirmed that caries lesions were limited to the facial and interproximal surfaces.|
Not surprisingly, clinicians are often faced with challenging caries treatment, management, and prevention cases that require balancing patient cooperation, cost, and treatment risk considerations in order to achieve the ideal outcome. Fortunately, a number of techniques and material advancements are available to help ensure both patient comfort during operative procedures and that treatment objectives for an improved and stable condition are accomplished. For example, IV sedation has been incorporated into operative protocol to facilitate a child’s or adolescent’s comfort during a wide variety of procedures, including sealants, restorations, root canal therapy, and extractions.7 In such cases, sedation and recovery have typically been uneventful.7 Additionally, to promote overall procedural accuracy and efficiency when placing direct restorations, a direct composite template system (such as Uveneer [Ultradent Products]) can be used to help achieve refined, anatomically correct restorations that require minimal adjusting or polishing. By facilitating the creation of correct restoration shape and symmetry during the placement process, as well as preventing the oxygen inhibition layer that would otherwise require removal, such templates enable efficient, one-visit treatments that are ideal for anxious patients when multiple restorations are necessary.
However, using a fast-setting, optically aesthetic, fluoride-releasing glass ionomer material (such as GC Fuji IX GP EXTRA [GC America]) is most significant in providing therapeutic treatments to anxious dental patients who have extensive caries due to a history of poor oral hygiene.8-10 Formulated to provide aesthetic restorations that more naturally match surrounding tooth structure, a fast-setting glass ionomer (ie, 2.5 minutes from initial mix) helps reduce chair time and ensures enhanced stability against oral fluids. More importantly, placing a glass ionomer that provides 6 times the initial fluoride protection of other materials maintains an excellent marginal seal and demonstrates requisite wear resistance and compressive strength that can help to ensure long-term caries prevention.
Diagnosis and Treatment Planning
A 13-year-old boy with a history of dental anxiety and poor oral home care presented with extensive caries lesions following the removal of his fixed orthodontic appliances (Figure 1).
A patient of record for nearly 10 years, he began orthodontics 2 years earlier, and he originally received pediatric prophies on a 6-month cycle. Not long into treatment, however, the orthodontist reported the patient’s poor oral hygiene habits, after which a meeting was held with the patient and his family to discuss the risks of poor home care, especially when fixed orthodontic appliances were in place.
Despite these discussions and additional hygiene coaching, the patient’s daily oral hygiene did not improve and, a few months later, the orthodontist reported a carious lesion under the bracket attached to tooth No. 6. Treating this lesion presented significant challenges due to the patient’s extreme fear of needles and rotary instruments. Behavior during this operative appointment was suboptimal, but the lesion was ultimately treated with air abrasion. Concurrently, it was noted that the patient’s oral hygiene had still not improved, and other teeth developed white spot lesions around the orthodontic brackets and gingival third regions. Together with the parents, monthly prophies to supplement his hygiene during the remainder of orthodontic treatment were agreed upon. Despite accomplishing this hygiene regimen, his homecare did not change, and lesions continued to progress.
In a subsequent follow-up discussion with the orthodontist, he noted that orthodontic treatment was completed and suggested quick treatment termination, developing a restorative plan, and ultimately placing definitive restorations. The patient’s orthodontic appliances were removed, and he presented the following week for examination and treatment planning.
|Figure 3. Unsupported enamel and remaining orthodontic resin were removed using a #2 round carbide bur (SS White Burs).||Figure 4. Dentinal carious lesions were removed using a glass-beaded, reinforced polymer round #4 bur (Smart Burs II [SS White Burs]) on low speed.|
|Figure 5. A diode laser (Pioneer Pro [Pioneer Lasers]) was used to recontour hyperplastic and inflamed gingival tissues.||Figure 6. Laser treatment enabled confirmation of the margins in a dry and easily visualized field.|
|Figure 7. The L size Uveneer (Ultradent Products) was selected to rapidly shape the glass ionomer material.||Figure 8. The preparations were conditioned for 20 seconds using a 20% polyacrylic acid solution (GC CAVITY CONDITIONER [GC America]).|
|Figure 9. A clear sectional matrix was placed on the mesial and distal of the tooth being restored.||Figure 10. GC Fuji IX GP EXTRA (GC America) was mixed and expressed into the preparation.|
Examination revealed the vast extent of carious lesions, but none appeared to extend into pulpal tissues. The lesions were generally isolated to the facial and interproximal surfaces (Figure 2), and pulp testing confirmed the vitality of all affected teeth. Given the patient’s age, extreme caution and a conservative approach to lesion removal were necessary to avoid pulpal exposures. Additionally, conservative soft-tissue management was needed to remove inflamed and hypertrophic tissue while also providing visualization and exposure of cavosurface margins.
Costs, risks, short- and long-term benefits and limitations, and treatment alternatives were discussed with the family. The agreed-upon treatment consisted of ultraconservative carious lesion removal and efficient, direct placement of 24 aesthetic glass ionomer cervical and interproximal restorations. To combat the patient’s situational anxiety surrounding dental procedures, it was agreed that IV sedation was needed to accomplish the extensive treatment plan. A board-certified anesthesiologist was consulted and performed the in-office anesthesia for the case. Due to the patient’s age, level of sedation, and cost factors, the agreed-upon time of anesthesia was limited to approximately 3 hours.
Following anesthesia, unsupported enamel and any remaining orthodontic resin were removed from the teeth using a #2 round carbide bur (SS White Burs) (Figure 3). The lesions were stained with caries detection dye to disclose the dentinal carious lesions.
Dentinal carious lesions were then removed using a round #4 bur (Smart Burs II [SS White Burs]) on low speed (Figure 4). The benefit of these glass-beaded, reinforced polymer burs is their selectivity for removing infected dentin, rather than affected dentin. This enabled an ultraconservative and rapid excavation of non-remineralizing dentin, a preservation of tooth structure, and a minimized pulpal exposure risk from overdrilling.
To recontour hyperplastic and inflamed gingival tissues, provide hemostasis, expose the gingival cavosurface margins, and disinfect inflamed tissues, an 810-nm diode laser (Pioneer Pro [Pioneer Lasers]) was used at a setting of 0.9 W CW (Figure 5). A dry and easily visualized field was achieved that enabled confirmation of the margins as well as lesion removal (Figure 6).
|Figure 11. The preselected Uveneer was positioned over the unset GC Fuji IX GP EXTRA.||Figure 12. Excess GC Fuji IX GP EXTRA was removed during the setting phase.|
|Figure 13. The final finishing and polishing was completed using fine diamonds and carbides.||Figure 14. Using the Uveneer to shape the material minimized finishing and polishing times.|
|Figure 15. Lesion removal and soft-tissue laser treatment were completed on the mandibular arch.||Figure 16. Immediate postoperative view of the glass ionomer restorations.|
|Figure 17. View at the 2-month followup.|
To initiate restorative procedures, the appropriate composite template (Uveneer) for rapidly shaping the glass ionomer material (GC Fuji IX GP EXTRA) was selected. Each numbered template corresponds to tooth number, tooth size, and the upper and lower arches. In this case, the L template was chosen (Figure 7).
The teeth were treated individually, beginning with the maxillary central incisors and working posteriorly. To increase the bond between the glass ionomer and tooth structure, the preparations were conditioned for 20 seconds using a 20% polyacrylic acid solution (CAVITY CONDITIONER [GC America]) (Figure 8), after which they were rinsed and not desiccated. A clear sectional matrix was then placed on the mesial and distal of the tooth being restored (Figure 9).
Based on the patient’s high caries risk, an optimized and high fluoride release and uptake glass ionomer restorative (GC Fuji IX GP EXTRA) in shade A2 was selected. Indicated for interim restorations and long-term provisionals and as an alternative to direct composite resins, the selected glass ionomer would also provide an exceptional marginal seal, high therapeutic performance, and easy polishability. The material was mixed and expressed into the preparation (Figure 10), and during the first 2.5 minutes from the start of the mix, extra care was taken to avoid moisture contamination and drying out.
The preselected Uveneer composite template was then immediately positioned over the unset material (Figure 11). The centerline of the template was aligned parallel to the facial midline and perpendicular to the incisal plane, and the concave side of the template was pressed firmly onto the tooth to remove any trapped air. Excess material was removed during the setting phase (Figure 12), after which the template was removed by gently lifting the handle. This process was completed individually on each tooth requiring restoration.
Once all of the glass ionomer restorative was set on all of the teeth in the arch, the final finishing and polishing was completed using fine diamonds and carbides (Figures 13 and 14). Protecting the interproximal regions with a clear sectional matrix prevented excess material from adhering to the neighboring teeth and, when combined with using the template to shape the material, significantly reduced cleanup time and minimized finishing and polishing times.
This same protocol for caries removal and soft-tissue laser treatment, as described above, was then completed on the mandibular arch (Figure 15).
Porcelain veneers may have provided the most ideal aesthetic result, but for this case, the techniques and materials were selected due to the patient’s current oral health and high-risk profile. Using a glass ionomer restorative material with high fluoride release (such as GC Fuji IX GP EXTRA) provided the patient 24 durable and aesthetic restorations at a limited cost and a minimized appointment time (ie, 3 hours) (Figure 16). A long-term, stable result was provided, and his dental condition was better than when he presented at a 2-month postoperative appointment (Figure 17), even if his oral hygiene and risk profile did not change. Due to the extensive nature of his carious lesions at such a young age, it is highly likely that more extensive restorations will be needed in the future.
- Seligman LD, Hovey JD, Chacon K, et al. Dental anxiety: an understudied problem in youth. Clin Psychol Rev. 2017;55:25-40.
- Duijster D, de Jong-Lenters M, Verrips E, et al. Establishing oral health promoting behaviours in children—parents’ views on barriers, facilitators and professional support: a qualitative study. BMC Oral Health. 2015;15:157.
- Carrillo-Diaz M, Crego A, Armfield JM, et al. Treatment experience, frequency of dental visits, and children’s dental fear: a cognitive approach. Eur J Oral Sci. 2012;120:75-81.
- Rantavuori K, Sihvonen A, Tolvanen M, et al. The significance of previous invasive and orthodontic treatment experiences on children’s dental fear. Eur J Orthod. 2014;36:409-413.
- Wright JT. The burden and management of dental caries in older children. Pediatr Clin North Am. 2018;65:955-963.
- Cagetti MG, Carta G, Cocco F, et al. Effect of fluoridated sealants on adjacent tooth surfaces: a 30-mo randomized clinical trial. J Dent Res. 2014;93(suppl 7):59S-65S.
- Hosey MT, Makin A, Jones RM, et al. Propofol intravenous conscious sedation for anxious children in a specialist pediatric dentistry unit. Int J Paediatr Dent. 2004;14:2-8.
- Mitra SB, Creo AL. Fluoride release from light-cure and self-cure glass ionomers. J Dent Res. 1989;68:274. Abstract 739.
- Tam LE, Chan GP, Yim D. In vitro caries inhibition effects by conventional and resin-modified glass-ionomer restorations. Oper Dent. 1997;22:4-14.
- Croll TP, Nicholson JW. Glass-ionomer cements: history and current status. Inside Dental Assisting. 2011;7:42-49.
Dr. Burden received his DMD degree from Temple University in 1999 and completed his hospital-based general practice residency at the Virtua Health System in New Jersey in 2000. He maintains a private practice in Millstone Township, NJ, where he focuses on minimally invasive general, aesthetic, and restorative dentistry. In 2007, Dr. Burden was awarded a Fellowship by the AGD, an honor attained by less than 6% of all practicing US and Canadian dentists. He can be reached at newparadigmdentistry.com.
Disclosure: Dr. Burden reports no disclosures.