Wednesday, September 20, 2017

The child’s voice: Understanding the contexts of Children and families today
Department of Pediatric Dentistry
                                                                             NYU Langone
Resident’s Name: Suhyun Rue                                                                                 Date: 09/20/2017
Article Title: The child’s voice: Understanding the contexts of Children and families today
Author(s): Harper, D. C. and D’Alessandro, D. M.
Journal: Pediatric Dentistry
Date: March-April 2004
Major Topic: Child behavior management and communication
Type of Article: Expert opinion
Main Purpose: Explore contemporary themes for improved contextual understanding of children and families today and their relationship to providing optimal pediatric dental care
Key Points: Enhanced communication and partnership building improves comprehension and compliance with dental treatment
·  Parenting practices have undergone significant changes in the past 15 years that have impacted children’s behaviors
·  Many factors have influenced parents’ disciplinary techniques with children
·  Pediatric dentists are expected to deliver care to children who may not always be as compliant as they need to be
·  Parenting practices
o Majority of surveyed pedodontists reported that parenting styles had changed for the worse during their career
o Availability of information influences parents, and increasing trend of raising children in violent environments
·  Childhood psychosocial problems
o Psychosocial problems are increasing in certain, if not all, demographics
o Inattentive behavior and impulsivity greatly affect compliance
·  Contexts for children’s dental interactions
o The child’s context is a function of age, health care experiences, and families’ existing attitudes toward dental health
o Younger patients are impressed with the newness of the office; they need to explore and move around
·  Parental and family contexts
o Parental expectations (of dentist, healthcare values, ability to pay, and lack of knowledge) influence family contexts
o If dentists ask for and provide basic educational information, they can increase competencies for dental care
·  Context for the pediatric dentist
o Dentists face difficult realities in treating disease within a limited time frame and decreased financial support
o Staff’s child orientation, style, and family centered approach are key in promoting positive dental care for families
·  Childhood fears and the dentist – difficult to distinguish fear and other personality characteristics (i.e. anxiety)
·  Developmental reactions of children – the reaction of fear differs throughout development
o Age 2-3 – more reactive to immediate situations and are literal in their framing of fears (strange places cause fear)
o Fears from age 4-8 are characterized as related to prior situations (past experiences and imaginative fears)
o By age 9 and older, fear is based more in personal failure and social peer situations
·  Changing families – the nuclear family has changed and child care has changed
·  Multicultural issues – beliefs and practices differ based on culture
·  Challenging children – difficult not only due to behavior, but also development, size, special needs, etc.
·  Pediatric pain management
o Effective methods for treating pain and fear of invasive procedures are pain medications, noninvasive techniques, and family-centered therapy
o Parental presence during invasive procedures may decrease parental anxiety
·  Communication suggestions
o Health care providers should begin to prepare children and parents at every opportunity.
o Multiple times over multiple days is key to successful communication
·  Behavioral management in pediatric dentistry
o Most behavioral management procedures are based on the general practice of distraction
·  Enhanced communication and partnership building improves comprehension and compliance with dental treatment
·  Diagnosing the child and family within the immediate local context is central to developing and accomplishing an effective dental treatment plan
Assessment of Article:  Level III – expert opinion

Tuesday, September 19, 2017

Effect on Behavior of Dental Treatment Rendered Under Conscious Sedation and General Anesthesia in Pediatric Patients

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Wayne Dobbins                                                                                           Date: 9/20/17
Article Title: Effect on Behavior of Dental Treatment Rendered Under Conscious Sedation and General Anesthesia in Pediatric Patients
Author(s): Fuhrer CR, Weddell JA, Sanders BJ, Jones JE, Dean JA, Tomlin A
Journal: Pediatr Dent 2009;31:492-497
Date: Nov/Dec 2009
Major Topic: Behavior Management
Type of Article: Retrospective Cohort
Main Purpose: To determine what differences, if any, existed between general anesthesia patients and conscious sedation patients, in the amount of time it took to exhibit positive behavior in the clinical setting after receiving their treatment with GA or CS.
Key Points: 

The study analyzed 80 ECC patients, age 36 months or less and without previous dental work, 41 of whom received conscious sedation and 39 of whom received general anesthesia. The conscious sedation regimen used in the study was as follows: chloral hydrate (50 mg/kg, max 1g) and hydroxyzine (1 mg/lb, max 25 mg), with nitrous oxide at 50 percent. The general anesthesia regimen used in the study varied; all GA treatment was conducted at the same hospital under the care of a pediatric anesthesiologist. The behavior recorded on subsequent recall visits (6 month, 12 month, 18 month) was analyzed according to the Frankl scale, but these analyses were conducted by different providers.

At their 6 month recall, patients treated under general anesthesia were 3.9 times as likely to exhibit good behavior as those treated under conscious sedation (P=0.0057) with statistical significance. At their 12 month recall, patients treated under general anesthesia were 1.9 times as likely to exhibit good behavior as those treated under conscious sedation (P=0.2469). At their 18 month recall, patients treated under general anesthesia were 2.25 times as likely to exhibit good behavior as those treated under conscious sedation (P=0.2481).

The odds ratio for 6 months was statistically significant, while those for the 12 and 18 month recalls were not statistically significant. No statistical significance was noted in behavior across ethnicity, gender, or by medical condition (asthma, sensory disability, sickle cell anemia, developmental delay). There was significant attrition throughout the study, particularly between 6 months and 12 months.

1. We do not know how successful their sedation protocol was. (What qualifies success?) If the sedations were not that successful, the children would have been less cooperative the next time. (second years and non successful sedations experiences?)
2. Over time the children got older, and would probably be more cooperative and receptive to simple behavior management, which can help explain the not statistical difference at 12 and 18 months.

Assessment of Article:  Level of Evidence/Comments: III

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name:      Olga Raptis                                                                             Date: 09-20-17
Root resorption associated with orthodontic tooth movement: A systematic review
Author(s): Belinda Weltman, Katherine Vig, Henry Fields, Shiva Shanker, and Eloise Kaizar
Journal: American Journal of Orthodontics and Dentofacial Orthopedics
Date: April 2010,   Volume 137, Number 4
Major Topic:  Root Resorption in Orthodontics
Type of Article: Systematic Reviews and meta-analysis of previous studies on
Main Purpose: Report the results from a rigorous systematic review of scientific literature that relates EARR in patients with fixed orthodontic appliances
Key Points: (2 lines Max):  1.) Found increased incidence and severity of root resorption in patients undergoing comprehensive orthodontic therapy 2.) Heavy forces produced significantly more RR than light force or in the control.  
EARR- External Apical Root Resorption
OIIRR- Orthodontically Induced Inflammatory Root Resorption

OIIRR of 90% in orthodontically treated teeth.
Incidence of EARR at 15% before treatment and 73% after treatment. Note that in most cases, the loss of root structure was minimal and clinically insignificant.

        Important facts:
  • Severe resorption, 4mm or one third of the original root length, occurs in 1-5% of teeth
  • There is some evidence that a 2-3 month pause in treatment decreases total root resorption. Teeth with a pause in active treatment in the first 6 months averaged RR of 0.4 +- 0.7 mm and those treated with continuous forces without a pause averaged 1.5 +- 0.8mm. 
  -  Teeth with the most RR (root resorption):
    1.              Max Incisors
    2.              Mand Incisors
    3.              Mand First Molars

  •      Orthodontic treatment-related risk factors include treatment duration, magnitude of applied force, direction of tooth movement, amount of apical displacement, method of force application (continuous vs intermittent), type of appliance, and treatment technique.
  •       Patient related risk factors include previous history of RR, tooth-root morphology, length, roots with developmental abnormalities, genetic influences, systemic factors, drugs (nabumetone), hormone deficiency, hypothyroidism, hypopituitarism, asthma, root proximity to cortical bone, alveolar density, chronic alcoholism, previous trauma, endo tx, severity and type of malocclusion, pt age, pt sex.   
  •      Note that teeth with trauma in 3 studies were noted to have similar rates of OIIRR to teeth without trauma, and did not study EARR.
  •      In combination, intrusion and lingual root torque are the strongest evidence for causing OIRR
  •      An average Max Central Incisor with 5mm of root resorption and no change in alveolar bone with still have 75% of its periodontal attachment remaining; “this explains why tooth loss from apical shorting has not been reported in the literature.”
Image result for root resorption

    The results were inconclusive in the clinical management of root resorption, but there is evidence to support the use of light forces, especially with incisor intrusion
    1- The results were inconclusive in the clinical management of root resorption, but there is evidence to support the use of light forces =, especially with incisor intrusion
    Assessment of Article:  Level of Evidence/Comments: Systemic Review 

    Sunday, September 17, 2017

    The Changing Nature of Parenting in America

    Resident’s Name:    Carol Caudill                                                                       Date: 9-20-2017
    Article Title: The Changing Nature of Parenting in America
    Author(s): Nicholas Long
    Journal: Pediatric Dentistry
    Date: 2004
    Major Topic: Parenting in America
    Type of Article: overview of a topic by an “expert”
    Main Purpose: To discuss how parenting has changed in recent decades in America
    Key Points: (2 lines Max): While we are focused on parenting now more than ever, stressors in today’s society make it difficult to parent effectively.
     ·     There is an increase of interest in parenting in recent decades.
    What pediatric dentists think
    ·      88% of board certified pediatric dentists believe that parenting styles have absolutely or probably changed during their lifetime
    ·      The dentists observed that: parents are less likely to use physical discipline and set limits on their child’s behavior and want to prevent any suffering a child may have from a dental procedure
    ·      85% of dentists believed these perceived shifts in parenting styles had resulted in somewhat or much worse patient behavior
    ·      These are only perceptions. No large-scale studies can clearly document parenting changes over recent decades.
    How much does parenting matter?
    ·      Parenting may be important but perhaps not as powerful as many might believe.
    ·      Genetic and peer influences may affect a child’s personality and character development more than parenting.
    ·      Parenting variables account for 20% to 40% of the variance in most child outcomes.
    The context of parenting
    ·      Children are also impacted by culture at the individual, family, community, and societal level.
    ·      The Index of Social Health for the United States quantifies how society is doing. It looks at things like drug abuse, unemployment, school dropouts, and homicides. From the early 1970s to the mid 1990s the index declined from the mid 70s to the low 40s meaning that the overall well being of our society decreased during that time. Decrease in society health can make it difficult for parents to parent successfully.
    Family trends
    ·      There is a trend for families to live increasingly isolated and disconnected lives in our society due to moving away from extended family, single parents, and free time limitations due to work schedules.
    ·      Parents have to spend more time working and less time providing for children’s emotional needs.
    ·      Families are under more financial stress than they have been in the past.
    The role of stress in shaping parenting changes
    ·      Stress may be a major factoring in parenting changes in society.
    ·      Parenting stress may be due to high workloads, low social support, negative life events, daily hassles, and difficult child temperament. Parenting stress is associated with inconsistent parenting, negative communication, decreased supervision, setting unclear rules, being more reactive, and increasingly harsh discipline.
    The impact of culture on parenting
    ·      As America becomes more ethnically and culturally diverse, there are more parenting approaches. As our society continues to become more diverse we need to remember that effective parenting practices in one ethnic group may not be an effective practice in another.
    1- Remember that parenting is difficult even in good circumstances, and that because of stressors in society it may be more challenging for the parents of our patient population
    Assessment of Article:  Level of Evidence/Comments: III

    Wednesday, September 13, 2017

    Resident’s Name: Michael Hatton                                                                   Date: 9/13/2017

    Article Title: Evidence-based orthodontics for the 21st century
    Author(s): Marc Ackerman DMD
    Journal: JADA
    Date: Feb 2004
    Major Topic: Orthodontics and evidence-based dentistry
    Type of Article: Review of Literature
    Main Purpose: Present evidence using orthodontic concerns that scientific evidence needs to be integrated into clinical orthodontic practice
    Key Points: (2 lines Max): communication is essential for 21st century orthodontics due to shift to patient autonomy and informed consent and true informed consent is not possible without integrating evidence-based dentistry
    This article addresses the use of data-driven advances in clinical orthodontics and how it may be used to influence the decision-making process (aka evidence based dentistry). The author focuses on the 2 questions that “100 years of orthodontic study has focused on”: 1) one-phase vs two-phase treatment of class II malocclusion and 2) extraction vs non-extraction treatment of arch perimeter deficiencies.
    In the American Association of Orthodontists definition of orthodontics, or dentofacial orthopedics, there is no mention of the psychosocial aspect of malocclusion and how the specialty may be able to treat this.
    With regards to one-phase vs two-phase treatment of class II malocclusion the author cited Tulloch, Phillips, and Proffit in 1998 with the findings that:
    a)      Result showed no difference in quality of dental occlusion between children who had early treatment and those who did not
    b)      Early treatment did not reduce number of patients needing premolar extraction in phase 2
    c)       Early treatment did not reduce eventual need for orthognathic surgery
    d)      Phase 1 treatment reduced phase 2 treatment roughly by 25% in general, and 2 phase treatment took in total took longer than 1 phase treatment in almost all cases
    CONCLUSION of Proffit: “preadolescent treatment for most children with Class II malocclusion is no more effective than later treatment, and is less efficient.”
    With regards to extraction vs non-extraction treatment of arch perimeter deficiencies the author cited Gianelly in 2003 and RPE, and Brennan and Gianelly in 2000 and space maintenance:
    a)      Maxillary arch perimeter can be increased (using RPEs) by 3-4mm making room for alignment of incisors
    b)      Found that by preserving “E” space in sample of patients with average of 4-5mm incisor crowding, 68% of patients had adequate space for alignment and 19% had adequate space with 1mm per side increase in arch length; and in such patients maxillary arch could be positioned over mandibular arch without need for RPE
    CONCLUSION: Decision of extraction vs non-extraction is multi-factorial, needing to view from “standpoint of a patient’s well-being in functional, esthetic and psychosocial areas.”
    Author also cited articles which indicated:
    1)      No evidence of beneficial effect of orthodontic treatment on future periodontal health
    2)      Occlusal patterns alone are unlikely to be the cause of hyperactivity of masticatory muscles associated with TMJ disorder
    Author found that with the shift of the decision-making process from one of paternalism to one of patient autonomy and informed-consent, communication between the practitioner and patient is crucial to arrive at the treatment decision. Author cited Chiccone 1990 and presented factors to incorporate into informed-consent. He also stated that without integrating accrued scientific evidence, it is impossible to present to the patient a “forthright and accurate cost/benefit analysis” and therefore be unable to truly obtain informed consent. 
    I would bring up the topic of when to refer early (excessive OJ and posterior crossbites) and why.
    Assessment of Article:  Level of Evidence/Comments: III