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National Guideline Clearinghouse (NGC). Guideline summary: Clinical guideline on pediatric restorative dentistry In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2004. Available: http://www.guideline.gov.

Bibliographic Source(s)

• American Academy of Pediatric Dentistry. Clinical guideline on pediatric restorative dentistry. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 9 p. [129 references]

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Category

Treatment

Intended Users

Dentists

Guideline Objective(s)

To assist the practitioner in the restorative care of infants children and adolescents

Target Population

Infants children and adolescents with tooth damage from dental caries who require restoration

Interventions and Practices Considered

1. Use of dentin/enamel adhesives
2. Use of pit and fissure sealants
3. Use of glass ionomer cements
4. Use of highly-filled resin-based composites
5. Amalgam restorations
6. Stainless steel crown (SSC) restorations
7. Labial resin restoration
8. Porcelain veneer restoration
9. Full-cast metal crown restorations
10. Porcelain-fused-to-metal crown restorations
11. Fixed prosthetic restorations
12. Removable prosthetic appliances

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

MEDLINE search

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify policies and guidelines may originate from 4 sources:

1. the officers or trustees acting at any meeting of the Board of Trustees
2. a council committee or task force in its report to the Board of Trustees
3. any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
4. officers trustees council and committee chairs or other participants at the AAPD's Annual Strategic Planning Session

Regardless of the source proposals are considered carefully and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.

The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed discussed and confirmed by the entire council.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Once developed by the Council on Clinical Affairs (CCA) the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision in which case it is returned to the council for modification once accepted by majority vote of the board it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly either as proposed or as amended by that body the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Dentin/Enamel Adhesives

The dental literature supports the use of tooth bonding adhesives when used according to the manufacturer's instruction unique for each product as being effective in primary and permanent teeth in enhancing retention minimizing microleakage and reducing sensitivity. (Garcia-Godoy & Donly 2002)

Pit and Fissure Sealants

1. Bonded resin sealants placed by appropriately trained dental personnel are safe effective and underused in preventing pit and fissure caries on at-risk surfaces. Effectiveness is increased with good technique and appropriate follow up and resealing as necessary.
2. Sealant benefit is increased by placement on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions. Placing sealants over minimal enamel caries has been shown to be effective at inhibiting lesion progression. Appropriate follow up care as with all dental treatment is recommended.
3. Presently the best evaluation of risk is done by an experienced clinician using indicators of tooth morphology clinical diagnostics past caries history past fluoride history and present oral hygiene.
4. Caries risk and therefore potential sealant benefit may exist in any tooth with a pit or fissure at any age including primary teeth of children and permanent teeth of children and adults.
5. Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique.
6. A low-viscosity hydrophilic material bonding layer as part of or under the actual sealant has been shown to enhance long-term retention and effectiveness.
7. Glass ionomer materials have been shown to be ineffective as pit and fissure sealants but could be used as transitional sealants. (Attin et al. 2001)

Glass Ionomer Cements

Glass ionomers cements can be recommended as:

1. Luting cements
2. Cavity base and liner
3. Class I II III and V restorations in primary teeth
4. Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated
5. Caries control:
   1. High-risk patients
   2. Restoration repair
   3. Alternative (atraumatic) restorative technique (ART) (Berg 2002)

Resin-Based Composites

Indications

The dental literature supports the use of highly filled resin-based composites in:

1. Small pit-and-fissure caries where conservative preventive resin restorations are indicated in both primary and permanent dentition
2. Occlusal surface caries extending into dentin
3. Class II restorations in primary teeth that do not extend beyond the proximal line angles
4. Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth
5. Class III IV V restorations in primary and permanent teeth
6. Strip crowns in the primary and permanent dentition

Contraindications

The dental literature recommends that resin-based composites not be used in the following situations:

1. Where a tooth cannot be isolated to obtain moisture control
2. In individuals needing large multiple surface restorations in the posterior primary dentition
3. In high-risk patients who have multiple caries and/or tooth demineralization and who exhibit poor oral hygiene and compliance with daily oral hygiene and when maintenance is considered unlikely (Donly & Garcia-Godoy 2002)

Amalgam Restorations

Dental amalgam can be recommended for:

1. Class I restorations in primary and permanent teeth
2. Two-surface class II restorations in primary molars where the preparation does not extend beyond the proximal line angles
3. Class II restorations in permanent molars and premolars
4. Class V restorations in primary and permanent posterior teeth (Fuks 2002)

Stainless Steel Crown (SSC) Restoration

1. Children at high risk exhibiting anterior tooth caries and/or molar caries may be treated with SSCs to protect the remaining at-risk tooth surfaces.
2. Children with extensive decay large lesions or multiple-surface lesions in primary molars should be treated with SSCs.
3. Strong consideration should be given to the use of SSCs in children who require general anesthesia. (Seale 2002)

Labial Resin or Porcelain Veneer Restoration

Veneers may be indicated for the restoration of anterior teeth with fractures developmental defects intrinsic discoloration and/or other esthetic conditions. (Horn 1983)

Full-Cast or Porcelain-Fused-to-Metal Crown Restoration

Full-cast metal crowns or porcelain-fused-to-metal crown restorations may be utilized for:

1. Teeth having developmental defects extensive carious or traumatic loss of structure or endodontic treatment
2. As an abutment for fixed prostheses
3. For restoration of single-tooth implants (Simonsen Thompson & Barrack 1983; Creugers van't Hof & Vrijhoef 1986; McLaughlin 1984)

Fixed Prosthetic Restorations for Missing Teeth

Fixed prosthetic restorations to replace 1 or more missing teeth may be indicated to:

1. Establish esthetics
2. Maintain arch space or integrity in the developing dentition
3. Prevent or correct harmful habits
4. Improve function (Simonsen & Calamia 1983 Thompson & Livaditis 1982; Wood & Thompson 1983)

Removable Prosthetic Appliances

Removable prosthetic appliances may be indicated in the primary mixed or permanent dentition when teeth are missing. Removable prosthetic appliances may be utilized to:

1. Maintain space
2. Obturate congenital or acquired defects
3. Establish esthetics or occlusal function
4. Facilitate infant speech development or feeding (Winstanley 1984; Abadi Kimmel & Falace 1982; Nayar Latta & Soni 1981)

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Abadi BJ Kimmel NA Falace DA. Modified overdentures for the management of oligodontia and developmental defects. ASDC J Dent Child 1982 Mar-Apr;49(2):123-6. PubMed



• Attin T Opatowski A Meyer C Zingg-Meyer B Buchalla W Monting JS. Three-year follow up assessment of Class II restorations in primary molars with a polyacid-modified composite resin and a hybrid composite. Am J Dent 2001 Jun;14(3):148-52. PubMed



• Berg JH. Glass ionomer cements. Pediatr Dent 2002 Sep-Oct;24(5):430-8. [103 references] PubMed



• Creugers NH van't Hof MA Vrijhoef MM. A clinical comparison of three types of resin-retained cast metal prostheses. J Prosthet Dent 1986 Sep;56(3):297-300. PubMed



• Donly KJ Garcia-Godoy F. The use of resin-based composite in children. Pediatr Dent 2002 Sep-Oct;24(5):480-8. [114 references] PubMed



• Fuks AB. The use of amalgam in pediatric dentistry. Pediatr Dent 2002 Sep-Oct;24(5):448-55. [63 references] PubMed



• Garcia-Godoy F Donly KJ. Dentin/enamel adhesives in pediatric dentistry. Pediatr Dent 2002 Sep-Oct;24(5):462-4. [35 references] PubMed



• Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983 Oct;27(4):671-84. [24 references] PubMed



• McLaughlin G. Porcelain fused to tooth--a new esthetic and reconstructive modality. Compend Contin Educ Dent 1984 May;5(5):430-5. PubMed



• Nayar AK Latta JB Soni NN. Treatment of dentinogenesis imperfecta in a child: report of case. ASDC J Dent Child 1981 Nov-Dec;48(6):453-5. PubMed



• Seale NS. The use of stainless steel crowns. Pediatr Dent 2002 Sep-Oct;24(5):501-5. [38 references] PubMed



• Simonsen R Thompson V Barrack G. Etched cast restorations: clinical and laboratory techniques. Chicago (IL): Quintessence Publishing; 1983.



• Simonsen RJ Calamia JR. Tensile bond strength of etched porcelain [abstract 1154]. J Dent Res 1983;61:297.



• Thompson VP Livaditis GJ. Etched casting acid etch composite bonded posterior bridges. Pediatr Dent 1982 Mar;4(1):38-43. PubMed



• Winstanley RB. Prosthodontic treatment of patients with hypodontia. J Prosthet Dent 1984 Nov;52(5):687-91. PubMed



• Wood M Thompson VP. Anterior etched cast resin-bonded retainers: an overview of design fabrication and clinical use. Compend Contin Educ Dent 1983 May-Jun;4(3):247-56 258. PubMed

Type of Evidence supporting the Recommendations

All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field.

Potential Benefits

The objectives of restorative treatment are to repair or limit the damage from dental caries protect and preserve the tooth structure re-establish adequate function restore esthetics (where applicable) and provide ease in maintaining good oral hygiene. Pulp vitality should be maintained wherever possible.

Potential Harms

Not stated

Contraindications

Resin-Based Composites

The dental literature recommends that resin-based composites not be used in the following situations:

1. Where a tooth cannot be isolated to obtain moisture control
2. In individuals needing large multiple surface restorations in the posterior primary dentition
3. In high-risk patients who have multiple caries and/or tooth demineralization and who exhibit poor oral hygiene and compliance with daily oral hygiene and when maintenance is considered unlikely

Qualifying Statements

As with all guidelines it is expected that there will be exceptions to the recommendations based upon individual clinical findings.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Resources

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Bibliographic Source(s)

• American Academy of Pediatric Dentistry. Clinical guideline on pediatric restorative dentistry. Chicago (IL): American Academy of Pediatric Dentistry; 2004. 9 p. [129 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Pediatric Dentistry

Guideline Committee

Clinical Affairs Committee

Restorative Dentistry Subcommittee

Composition of Group that Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available from the American Academy of Pediatric Dentistry Web site.

Print copies: Available from the American Academy of Pediatric Dentistry 211 East Chicago Avenue Suite 700 Chicago Illinois 60611

Availability of Companion Documents

Information about the American Academy of Pediatric Dentistry (AAPD) mission and guideline development process is available on the AAPD Web site.

The following implementation tools are available for download from the AAPD Web site:

• Dental growth and development chart
• American Academy of Pediatric Dentistry Caries-Risk Assessment Tool (CAT)

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on March 16 2005. The information was verified by the guideline developer on April 18 2005.

COPYRIGHT STATEMENT

This summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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