Sunday, August 20, 2017

 Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood
Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Suhyun Rue                                                                          Date: 8/23/2017



Article Title:  
Associations between fluorosis of permanent incisors and fluoride intake from infant formula, other dietary sources and dentifrice during early childhood
Author(s):
Steven M. Levy; Barbara Broffitt, Teresa A. Marshall; Julie M. Eichenberger-Gilmore; John J. Warren
Journal:
Journal of American Dental Association
Date: 10/2010
Major Topic:
Associations between dental fluorosis and fluoride intakes, with an emphasis on intake from fluoride in infant formula
Type of Article: case control cohort study
Main Purpose:
1- Describe associations between fluorosis in the permanent maxillary incisors and fluoride consumed during infancy and early childhood.
2- Estimate risks associated with using substantial amounts of powdered infant formula reconstituted with fluoridated water.

Key Points/Summary:
Objectives:
-         - Fluoride can be ingested from both dietary and nondietary sources. The primary source of dietary fluoride is water. The primary sources of nondietary fluoride are oral health products aimed at caries prevention, such as dentifrices, mouth rinses and gels.
-          -The critical period for development of fluorosis in permanent maxillary central incisors, the most prominent teeth esthetically, is during the period from birth through age 4 years.
-          -Other researchers showed that consumption of infant formula was associated with increased risk of at least some detectable level of enamel fluorosis.
Methods:
-        -  The authors administered periodic questionnaires to parents (n=630) to assess children’s early fluoride intake sources from beverages, selected foods, dentifrice and supplements (1.5, 3, 6, 9, 12, 16, 20, 24, 28,32 and 36 months).
-     -The examiners used the Fluorosis Risk Index (FRI) to assess dental fluorosis (FRI  score 2 and 3).        -Exclusion criteria: 1-Cervical zones / 2-One central incisor involvement.
      -Case participants: if they had fluorosis on two or more permanent maxillary incisors / control participants:  if they had no fluorosis on maxillary incisors.
     - The authors determined effects associated with fluoride in reconstituted powdered infant formulas, along with risks associated with intake of fluoride from dentifrice and other sources.

Result:
-          -Fluoride intake from ages 3 to 9 months: Participants with fluorosis had significantly greater fluoride intake from powdered infant formula and other beverages with added water than those without fluorosis.
-        -  Fluoride intake from ages 16 to 36 months: Participants with fluorosis had significantly higher fluoride intake from dentifrice ingestion than those without fluorosis.
-          -In a model combining both the 3 to 9 months and 16 to 36 months age groups, the significant variables were fluoride intake from powder concentrate formula and other beverages with added water ( for  participants at ages 3-9 months) and dentifrice ingestion (for  participants at ages 16-36 months).

Discussion:
-         - Median total formula intakes were about 8 percent higher in children with fluorosis, but median fluoride intakes from infant formulas were 80 percent higher. Thus, fluorosis was not associated with the quantity of formula consumed but rather associated with the amount of fluoride in the formula 
-         - Fluoride intake from selected food sources prepared with water at home was slightly higher with fluorosis than in those without fluorosis. This suggests that fluoride intake associated with food preparation had less effect on fluorosis risk than did the intake from beverages
-          -97% of the fluorosis in this study was mild. A recent review of the effect of mild dental fluorosis on oral health-related quality of life concluded that the effect of mild fluorosis was not adverse and could even be favorable. This suggests that concerns about mild dental fluorosis may be exaggerated. Thus,
T no general recommendations to avoid use of fluoridated water in reconstituting infant formula are warranted.

-          Conclusion:
-         -  At younger ages ( 3-9 months), fluoride intakes from the fluoride in formula reconstituted with water and the fluoride in tap water added to beverages; at older ages ( 16 to 36 months), it was from dentifrice ingestion.
- For those concerned about reducing risk of developing mild fluorosis, dentist or physician should provide recommendations to use water with lower fluoride levels and to use small ( smear or pea-sized) amounts of fluoridated dentifrice with proper supervision of the child’s tooth brushing.


Assessment of Article:  Level of Evidence/Comments:  Level II Cohort study

Wednesday, August 16, 2017

Effect of Sliver Diamine Fluoride (SDF) Application on Microtensile Bonding Strength of Dentin in Primary Teeth

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: Michael Hatton                                                                                 Date: 8/16/2016
Article Title: Effect of Sliver Diamine Fluoride (SDF) Application on Microtensile Bonding Strength of Dentin in Primary Teeth
Author(s): Wu DI, Velamakanni S, Denisson J, Yaman P, Boynton JR, Papagerakis P
Journal: Pediatric Dentistry
Date: Mar/Apr 2016
Major Topic: Restorative and Preventive Dentistry
Type of Article: Case control
Main Purpose: To assess the microtensile bonding strength of composite to dentin previously treated with SDF.
Key Points: SDF application has no effect on microtensile bonding strength.
 Previously extracted primary second molars were sterilized in formalin and then prepared for analysis. The occlusals were ground flat to expose dentin and the teeth were sectioned in half, with one half receiving SDF and the other serving as a control. Composite was bonded in the usual manner and then these sections were prepared into vertical rods 1mm in cross section, which were then stressed until fracture.
There was no significant difference in bond strength between the control group and the experimental group based on force required to fracture. However, in the SDF group, fracture was more likely to occur entirely within the adhesive layer than in the control group, where the fractures were more likely to occur at the junction of the adhesive material with the dentin, implying that the dentin-adhesive bond in the SDF group may have been stronger.

The primary confounding factor of the study was that, clinically, SDF is not applied to non-carious, non-sclerotic dentin that has been ground flat in a laboratory setting. Thermocycling was not used and no effort was made to simulate aging or natural wear.

Remarks:
There was no significant difference in bond strength between the control group and the experimental group. The primary confounding factor of the study was that, clinically, SDF is not applied to non-carious, non-sclerotic dentin that has been ground flat in a laboratory setting. Thermocycling was not used and no effort was made to simulate aging or natural wear.
Assessment of Article:  Level of Evidence/Comments: II-3



Mutans Streptococci: Acquisition and Transmission

Resident’s Name: Brian Darling                                                                                 Date: 8/16/2017

Article Title: Mutans Streptococci: Acquisition and Transmission
Author(s): Robert J. Berkowitz
Journal: Pediatric Dentistry
Date: 2006; 28: 106-109
Major Topic: Mutans streptococci (MS) acquisition and transmission in children and its implications for dentistry.
Type of Article: Conferenc paper
Main Purpose: This article aimed to describe recent evidence that MS can colonize the mouth before teeth erupt and recommendations to reduce early transmission of MS to children.
Key Points: (2 lines Max): MS can colonize infant mouths before teeth erupt. Preventing early MS colonization in children reduces the risk of caries.  
·      Swallowing occurs every few minutes.
·      Previous evidence demonstrated that MS could not be detected (and thus colonize) infant mouths before the eruption of primary teeth. However, MS could be detected in predentate infants though in infants with acrylic cleft palate obturators.
·      Recent studies have been able to detect MS in predentate infants, especially from the furrows of the tongue. This raises doubt that a nonshedding oral surface (ie teeth) is required for MS colonization.
·      Early acquisition of MS is a major risk factor for ECC and future caries
o   In one study, presence of MS at 1 year of age was the most effective predictor of caries at 3.5 years of age (compared to fluoride exposure, dietary habits
·      Vertical Transmission: transmission of microbes from caregiver (usually mother) to child
·      Mothers with high MS levels are at increased risk of transmitting MS to their infants earlier in life
·      Efforts to reduce MS levels in mothers with high levels of MS (chlorhexidine rinses and xylitol gum chewing) have been shown to delay the acquisition of MS in infants
·      Infants delivered by Caesarian section acquire MS earlier than infants born from vaginal delivery
·      Horizontal Transmission: transmission of microbes between members of a group (family members of a similar age or students in a classroom)
·      Primary infection of MS may occur in predentate infants
·      Recommendations:
o   Reduce the MS reservoir in mother, siblings, and infant’s caretakers by eliminating active caries and using agents such as fluorides and chlorhexidine
o   Alter saliva-sharing activities, such as tasting food before feeding and sharing toothbrushes
o   2x/day brushing in dentate infants with ADA approved toothpaste
o   Avoid decay promoting feeding behaviors

Remarks:
1-
2-
Assessment of Article:  Level of Evidence/Comments: III

The role of chlorhexidine in caries prevention

Resident’s Name: Brian Darling                                                                                 Date: 8/16/2017

Article Title: The role of chlorhexidine in caries prevention
Author(s): Jaana Autio-Gold
Journal: Operative Dentistry
Date: 2008; 33: 710-716
Major Topic: Chlorhexidine and its effect on caries
Type of Article: Literature Review
Main Purpose: This article aimed to describe the current evidence on chlorhexidine and its effect on caries prevention.
Key Points: Although there are mixed and some promising results from studies about chlorhexidine gels and varnishes, there is currently insufficient evidence for it to be recommended for use in caries prevention.
·      The most persistent mutans streptococci (MS) reductions by chlorhexidine delivery systems are achieved by varnishes followed by gels and then mouth rinses.
·      Only 0.12% chlorhexidine mouthrinses are marketed in the US
·      People with higher levels of MS develop more caries
·      Studies on the effect of chlorhexidine mouthrinses have failed to show a significant effect on caries reduction
·      There is a small body of evidence that chlorhexidine gels may be able to reduce caries in children. More studies are needed to validate the effectiveness of chlorhexidine gels. 
·      Reducing the levels of plaque and/or MS may not always correlate with a reduction in caries 
·      Chlorhexidine varnishes were developed to increase the substantitivity, length of time of suppression, and effectiveness of the delivery of chlorhexidine to sites colonized by MS
·      There is a small body of mixed evidence regarding the effectiveness of chlorhexidine varnish to reduce caries
·      Some studies in vivo and in vitro have shown combinations of fluoride and chlorhexidine to be synergistic against MS. However, clinical trials of fluoride and chlorhexidine combinations have not demonstrated this combination to provide an additional preventive effect
·      The main clinical problem of chlorhexidine is the difficulty in suppressing or eliminating MS for an extended period of time
·      Pre-treatment MS levels are generally reached within 2-6 months after chlorhexidine treatment.
o   There must be reservoirs or retentive sites in the dentition that are not or hardly affected by the chlorhexidine treatment.
o   Patients with more retentive sites such as faulty restorations, occlusal fissures, enamel cracks, incipient lesions, and patients with orthodontic appliances were more rapidly colonized by MS
·      Chlorhexidine staining as a side effect:
o   Yellow-brown staining
o   Usually occurs in cervical third of crown and in interproximal areas
o   Most pronounced staining occurs along CEJ or root surface, in pits and fissures, and existing composite restorations and occasionally the tongue
o   Staining occurs in one-third to ½ of patients
o   Usually evident within several days after initiation of daily rinses
o   Removable with the exception of porous restorations or open margins
·      Altered taste sensation is a side effect of chlorhexidine that usually lasts several hours but is uncommon and self-limiting
·      Chlorhexidine rinses should not be recommended for caries prevention
·      Use of different chlorhexidine modes or a combination of chlorhexidine-fluoride therapy for caries prevention has been “suggestive but incomplete”

Remarks:
1-
2-
Assessment of Article:  Level of Evidence/Comments: III