The best pediatric dental restorations

Q: Recently, I was talking to some of my dentist-friends and our conversation turned to the ongoing dental caries activity observed in our pediatric patients. We discussed potential preventive/restorative alternatives and disagreed on the kind of restorative material to use, since amalgam has been criticized and composites dominate restorative dentistry. The majority of my peers are using resin-based composites for their pediatric patients. I am pondering the question and would like to hear your comments about how to best restore the teeth of pediatric patients.

A: There are several alternatives for the restoration of pediatric teeth, some of which are well proven and others that still need long-term research. This discussion relates to restoration of both primary and permanent teeth in children and teenagers. In this column, I recently discussed the use of the new-generation glass ionomer restorative materials. Please refer to that article in the January 2021 issue of Dental Economics. Even just a few years ago, glass ionomer materials would not have been included in my suggestions due to the difficulty in working with them and their physical properties. But that has changed. The new glass ionomer restorative materials will be strongly recommended in my answer.

The wide diversity of restorative challenges and needs among pediatric patients should be part of our discussion. Those needs are directly related to the dental education parents provide to their children and the level of parental supervision of oral hygiene. It is unlikely that children will have good oral hygiene habits if their parents are not knowledgeable about caries and how to prevent this most commonly occurring childhood disease (figure 1).

Figure 1: This is one of my grandchildren. I have followed her oral care since her birth. She has had systemic and topical fluoride, sealants, and good home care. She has lived in an area with a nonfluoridated water supply all of her life and is now a 30-year-old registered nurse. Unlike many children, she has had only one minor class I lesion. Such a situation is possible but not probable without the use of fluoride-containing procedures, a reasonably healthy diet, and good oral hygiene. — **Figure 1:** This is one of my grandchildren. I have followed her oral care since her birth. She has had systemic and topical fluoride, sealants, and good home care. She has lived in an area with a nonfluoridated water supply all of her life and is now a 30-year-old registered nurse. Unlike many children, she has had only one minor class I lesion. Such a situation is possible but not probable without the use of fluoride-containing procedures, a reasonably healthy diet, and good oral hygiene.

Levels of dental needs among children are similar to those of adults. The condition of a child’s mouth on the initial exam is highly predictive of what to expect in the future and the type of restorative material that will be needed. The following discussion will describe several categories of currently available restorative materials in addition to the types of patients those materials would be appropriate for as preventive measures.

Restorative material alternatives for patients

My personal preferences will be reflected in the following prioritized list of restorative alternatives and may not match the order you prefer. Note that the older conventional materials are listed near the bottom.

New conventional glass ionomers (GI) have easier working characteristics, greater strength, and faster set than previous GI restoratives. Examples: Equia Forte or Equia Forte HT (GC America), IonoStar Plus (Voco), Ketac Universal (3M).
Resin-modified glass ionomers (RMGI). Examples: Fuji Automix LC (GC America), Ketac Nano (3M), Riva LC HV (Southern Dental Industries).
Options 1 or 2 above with a layer of resin-based composite of your choice on the occlusal surface.
Resin-based composite of your choice.
Compomer. Example: Dyract Extra (Dentsply Sirona).
Amalgam of your choice.
Zirconia-prefabricated crown. Example: NuSmile ZR Zirconia (NuSmile).
Stainless steel crowns. Examples: 3M, 3S Stainless Steel Kit (Acero Crowns).

Let’s discuss how to select the best type of restorative material based on the patient’s age and degree of caries activity.

Minimal caries activity and small tooth preparations

New GI materials (no. 1) have been recommended by the respective companies for small class I and II situations as well as class III and V situations. These materials are far easier to use than previous generations of conventional GIs. They attain a putty consistency soon after being mixed, and they lack the sticky characteristics of the older products. Their major advantages are extremely high fluoride release and actual seal of the cavity preparation margins. These desirable characteristics have been proven by sophisticated chemical analysis of fluoride release and electron microscope evaluation of in vivo specimens of restorations up to three years in service (Clinicians Report Foundation, TRAC division). This is the first category of restorative materials to receive such achievements in the long history of research by Clinicians Report Foundation.

The undesirable characteristics of these materials are more wear, less strength, and less adequate esthetic characteristics than the current generation of resin-based composites. These material characteristics limit their use in moderate-to-large restorations, but do not limit their use on the internal portions of moderate-to-large restorations.

RMGI (no. 2) is also a good alternative for these patients. However, the current materials are somewhat sticky and do not have the same seal of the prep or high fluoride release as the conventional GIs. An advantage of these materials is the light-cure capability of the approximately 20% resin component of the RMGI material, facilitating somewhat easier finishing.

Resin-based composite (no. 4) is a choice if you estimate the caries activity is minimal. However, composite has no cariostatic activity and the margins of all composite restorations have been shown by scanning electron microscope to be wide open, despite being undetectable to the naked eye.

Compomer (no. 5) is used in some countries for pediatric patients. It is a puttylike hydrophilic resin with easy light-curing characteristics and slight fluoride release. It has the similar negative characteristics of resin-based composites.

Amalgam (no. 6) is still used by many dentists worldwide, but numerous public health organizations have suggested not using it in children or pregnant women, and some countries have even banned it. After decades of personal research, my personal opinion is that the allegations about problems with amalgam are exaggerated. The choice of whether to use amalgam is up to you, but it will probably eventually be banned by most countries.

Moderate caries activity and moderate-to-large tooth preparations

I suggest no. 3. Restoring this category of patient requires careful prediction of the apparent expected caries activity, observable oral hygiene, and parent supervision. Preventive materials are highly encouraged. I suggest the following procedure.

Disinfect the prep with 5% glutaraldehyde 35% HEMA (Gluma or MicroPrime) in two one-minute applications. Place GI (no. 1) in the prep nearly to the margin areas, letting the material set somewhat. Acid-etch it and the enamel, wash, place a bonding agent of your choice, and follow with placement of the composite of your choice.

This alternative offers seal of the internal area of the prep, high fluoride release for prevention, composite wear resistance, color, and strength on the occlusal surface. It satisfies most of the restorative needs for these types of patients.

RMGI (no. 2) can be substituted for the GI, but with fewer desirable or preventive characteristics.

High caries activity and large tooth preparations

Two crown choices are available: stainless steel or zirconia. Stainless steel crowns are the easiest to use, but many parents prefer zirconia crowns for esthetics.

RMGI cement is highly advised for either type of crown. Examples: RelyX Luting (3M), FujiCem Evolve (GC America).

Summary

Unfortunately, the most commonly occurring childhood disease—dental caries—is still present. This self-inflicted disease is almost totally preventable, but it is highly unlikely that it will ever happen with the current preventive techniques available and the lack of patient compliance. Improved preventive materials are now available, primarily the new generation of glass ionomer cements. These materials are changing restorative procedures for children and should be considered over previously used concepts.

Author’s note: The following educational materials from Practical Clinical Courses offer further resources on this topic for you and your staff.

One-hour videos:

The NEW Glass Ionomers Really Work (Item V3514)
Treating the Aging Population—A Frustrating Challenge (Item V4777)

Two-day hands-on courses:

Restorative Dentistry 1—Restorative/Esthetic/Preventive with Dr. Gordon Christensen
Faster, Easier, Higher Quality Dentistry with Dr. Gordon Christensen

For more information about these educational products, call (800) 223-6569 or visit pccdental.com.

Gordon J. Christensen, DDS, PhD, MSD, is a practicing prosthodontist in Provo, Utah. He is the founder and CEO of Practical Clinical Courses, an international continuing education organization founded in 1981 for dental professionals. Dr. Christensen is cofounder (with his wife, Rella Christensen, PhD, RDH) and CEO of Clinicians Report.