Wednesday, December 28, 2011

Nutrition and Oral Health Considerations in Children with Special Health Care Needs: Implications for Oral Health Care Providers

Resident’s Name: Matthew Freitas
Author(s): A.M. Moursi et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2010. 32:4. 333-342.
Major topic: Special Needs

Purpose: The purpose of this article was to discuss: nutritional and oral health factors routinely observed in most chronic childhood disorders; dietary modifications associated with select systemic disorders and how they may impact oral health in children.

Childhood Disorders that commonly require dietary modifications:
1. Congenital Heart Disease- anatomic and physiologic changes of the heart and circulation.
2. Cystic Fibrosis- autosomal-recessive, inherited disorder characterized by impaired exocrine and mucus secreting glands.
3. Cancer- uncontrolled growth of abnormal cells and the capacity to invade nearby tissues and metastasize to distant sites.
4. AIDS/HIV- immune system begins to fail, leading to life-threatening opportunistic infections.
5. Diabetes Mellitus- most common endocrine disease, resulting in hyperglycemia.
6. Phenylketonuria- inherited metabolic disorder characterized by a deficiency in the enzyme that metablolizes the amino acid phenylalanine, causing accumulation and neurological deterioration.

Recommendations for management of nutrition and oral health in children with medically restricted diets:
1. Dietary management- AAPD endorses the Dietarian Guidelines for Americans and The Food Guide Pyramid as guides to daily food choices. Use of high-density foods to increase energy and nutrient levels may be beneficial.
2. Oral health management- AAPD recommends establishing a dental home by one year of age. Early and aggressive preventative treatment as well as frequent recall visits is critical.
3. Oral hygiene management- reinforcement of good oral hygiene at home. 2-2-2 rule: soft-nylon toothbrush for 2 minutes; 2 times a day (after breakfast and before bed), with nothing entering the mouth for 2 hours after spitting without rinsing. Caregiver should brush child's teeth until age of 7-8 yrs age.
4. Antimicrobial products, Remineralization, and xerostomia - chlorhexidine rinses (alcohol [Peridex] or water-based [better for xerostomia patients]), gels, fluoride varnishes and xylitol. It is important to note that many sugarless gyms containing xylitol also contain phenylalanine and are contraindicated for phenylketonurics.

Conclusion:-Early intervention by the oral health provider with aggressive preventive therapy and reinforcement of good oral hygiene should be advocated to minimize potential oral health problems derived from restricted diets.

Improving Systems of Care for People with Special Needs: The ASTDD Best Practices Project

Author: Balzer, Jay, DMD, MPH

Journal: Pediatric Dentistry, vol 29, March/April, 2007

Reviewed by: Fotini Dionisopoulos, DMD

Purpose: To review the potential of how the Association of State and Territorial Dental Directors' (ASTDD) Best Practice Project can improve health care for people with special oral health needs and to highlight three successful practices who care for those with special needs.

Key Points:
The mission of the ASTDD Best Practices Project is to serve as a resource to share ideas and cultivate best practices for state and community oral health programs.

1) The ASTDD Best Practices Poject purpose is to help states develop their best practices and to help build a supportive environment for these best practices

2) The area of Special needs is a new best practice approach being prepared for the ASTDD Best Practices Project.

3) The framework for the project includes the following:
-prepare the dental workforce to serve people with special needs
-create a more responsive financing system for special needs patients
-organize community resources for more access for special needs patients
-empower parents and caregivers to promote advocacy to improve the oral health of special needs patients

4) Three practices were highlighted in the article:

Fellowship Program at Rose Kennedy University Center for Excellence in Developmental Disabilitities/Albert Einstein College of Medicine-- excellence was in in preparing the dental workforce to serve special needs patients; provides comprehensive care in all aspects of special needs dentistry- from training in genetics to treatment under general anesthesia. The program provides close interaction with public helath, developmental disabilities community, pediatric and GPR residents who rotate through the program.

Special Smiles Program-Pediatric Dental Associatiates, Philadelphia, PA -- excellence in approach to make the fiancing system more responsive to special needs paitents: uses Medicaid funds to create a new source of specialized care, accepts virtually all patients referred to the program, provides general anesthesia on an outpaitent basis, and contracts full-time anesthesia services rather than case-by case, obtains facility space as an in-kind contribution, rather than paying rent at market rates- adding to its financial effiency.

Butler County Dental Case Management System -- excellence in approach to organizing community resources to improve access to care-- a dental case manangement program was initiated as a result of feedback from the community that patients with special needs had lack of access to care--with use of funds that already existed within that community.

The goal of the article, was to "encourage and inspire" states, communities, and the dental profession to establish what is necessary to improve the oral health status of those patients with special needs.

Assessment: As we encounter more patients in private pediatric offices with special needs, especially with autism being more prevalent in society--there is every reason to have a need for improved access to care for special needs patients, especially as they become older and it is less effective to care for them in our private offices. There is a major need to provide feasible access to care for these patients, especially as they get older.

Oral Findings in Special Needs Kids with G-tubes

See if you can find me at the summit of this Utah mountain.

Resident: Swan

Article Title: Comparison of Oral Findings in Special Needs Children With and Without Gastrostomy.

Authors: Jawadi, et al.

Journal: Pediatric Dentistry 26:3, 2004 pg 283.

Purpose: 1. Measure oral parameters and organisms related to aspiration pneumonia (AP) in kids with gastrostomy tube (GT) and controls. 2. assess relationship between health behaviors, miroorganisms, plaque, calculus, and history of AP.


Reasons a child might have a G-Tube for feeding:
1. difficulty swallowing, 2. failure to thrive, 3. inadequate caloric intake, 4. feeding disorder,
5. severely disabled w/ poor nutritional status, 6. GI tract obstruction.

Placement of GT in kids has been linked to GER and has also been associated with Aspiration Pneumonia (AP). AP is caused by entry of infectious pharyngeal contents into the lower airway. So pharyngeal bacteria is a major source of infection in AP. Organisims responsible include Bacteroides, Fusobacterium, porphyromonas, etc--ie the common anaerobes of the mouth and pharynx.

GT feeding has been associated with poor oral hygiene an low salivary flow, which can make for a very concentrated bacterial inoculum that, when aspirated, could introduce pathogens to the lungs. The investigators hypothesized that reducing oral organisms might reduce AP morbidity in children. Their study was driven by the clinical dilemma of when and how often calculus buildup in these patients should be scaled.

Methods: 26 kids with the following criteria were selected from the Special Needs/Gastrostomy Tube patient base followed at Columbus Children's Hospital: 1. 3 to 12 yrs old, 2. documented swallowing difficulty, 3. GT feeding or at least 1 yr., 4. enough teeth erupted for scoring, 5. receiving daily OH from caregiver.

Control group drawn from same patient base of special needs children, but these kids did not have G tubes. The study and control groups were matched for age, gender, race, and major medical diagnoses.

A questionnaire was given to each parent and a clinical exam performed on the child. Examination included teeth charting, Gingival Index and calculus measurement. A salivary sample was also taken from under the tongue.

Main Findings
1. GT group took almost 4 times as many medications than controls
2. GT group experienced significantly more pneumonia, vomiting, and constipation than controls.
3. GT with Aspiration Pneumonia group had significantly more calculus and plaque than controls.
4. GT with AP group had significantly higher H. Influenzae and Pseudomonas counts compared to controls.
5. the groups did not differ significantly when comparing number of hygiene visits or frequency of brushing.

1. Calculus was significantly related to Aspiration Pneumonia
2. GT children were significantly more likely to have calculus; GT children more likely to experience AP.
3. dental visit frequency had no relationship to AP.

Assessment: This study was very thorough and well done. The authors point out that while calculus removal for these patients would seem to reduce a highly significant risk factor for AP, more research and replicated findings would be needed to advocate for more frequent professional visits, especially given the fact that OR treatment is the only feasible option for many of these patients.

Parental Perceptions of Oral Health-related Quality of Life for Children with Special Needs: Impact of Oral Rehabilitation Under General Anesthesia

Resident: Cho
Date: 12/28/11

Author(s): Baens-Ferrer et al.
Journal: Pediatric Dentistry, 2005

Type of Journal: Scientific Article

Purpose: Describe the child’s oral symptoms and daily life problems and parents’ concerns related to oral health for their children with SHCN; examine the effectiveness of oral rehabilitation under general anesthesia at improving QOL, as reported by parents/family caregivers.

Methods: Over 7-month period, 107 children with SCHN were recruited for the study. Family caregivers were given oral health-related QOL survey at the time of their child’s dental examination if the child was recommended for treatment under G.A. Follow-up surveys were conducted by mail. Dental record reviews were collected for demographic and clinical variables.

Key points in the article discussion:

Of the group of 107, 47 patients had severe dental anxiety due to age or trauma, 16 patients had autism, 11 patients had CP, 10 patients have genetic disorders, and the remaining patients had either MR, neurologic condition, cardiac condition, behavioral/psychiatric disorder, learning disability/ADD, or other conditions. 73/107 elected to have G.A. Spontaneous toothache/pain with hot/cold temperatures were the most frequently reported symptoms prior to oral rehabilitation. Most frequent reported daily life problems were difficultly eating, refusing certain foods because of pain, and difficulty falling to sleep and waking up from sleep due to pain. The most frequent parental concern was worrying about eating and nutrition. The comparison of mean scores from initial to follow-up surveys showed that G.A. was effective at minimizing or alleviating oral symptoms, daily life problems, and parental concerns.

Assessment of article: Great article! Yay Dr. Baens! Helpful article for those doing surveys for research projects.

Perspectives of a Parent and a Provider for Children with Special Health Care Needs

Perspectives of a Parent and a Provider for Children with Special Health Care Needs

by Purnima J Rathi hernandez, DDS, MA

Pediatric Dentistry V29/No2 Mar/Apr 2007

Resident Meg

Abstract: A Pediatric Dentist who treats children with special health care needs finds herself the mother of a child with special needs. She offers a different perspective into treatment for these patients and her own experiences as both a dentist and a mother.


Because this article was more of a short story I'll just mention a few of my favorite and memorable parts:

"We knew that our child would have disabilities, the extent of which only time would tell. It was very difficult to accept. We felt a strong sense of loss, guilt, denial, and anger."

-Her thoughts here remind me of many of our cranio-facial families. There is much more to just "treatment" of these patients . Often times parents need help, advice or just someone to talk to. We must as providers be aware of the social aspects of treating these families.

"I see my life differently today. Although difficult, my life is not a tragedy. It has presented me with amazing opportunities to learn and influence the world around me. And I accept this challenge with honor."

"The most important lesson I’ve learned is that a person with disabilities is not less of a person. Disability does not define a person, but disability is a medical diagnosis—which becomes a sociopolitical passport to obtain services."

"Parents of CSHCN expect that the provider will:

1. have the patience and time to treat their child, even though commercial insurances don’t recognize or reimburse for longer visits;

2. Not underestimate the ability of the child to accept treatment; the provider will persevere, improvise and learn ways to treat the child in the office—treatment in the operating room should be the exception, not the rule."

-Parents expect the Dentist to be knowledgeable about the disease, developmental disability or special care issue.

This quote I especially loved. It showed how reliant we've become on treating these children in the OR. The author states that treatment in the OR should not be the norm, it should be the exception.

"Children become adults. They need to learn from the time they are young that a dental visit is safe and something they can learn to accept. This is true for all children, whether they have a disability or not. I believe that even children with a cognitive disability have the capability to learn this with intensive exposure. Obtaining OR approval from medical insurances is getting more difficult by the day."

The author mentions that repeated exposure and structured environments are tools we can use to desensitize these patients.

Here is her five step plan:

To best accommodate patients for these long visits, I have developed guidelines such as:

(1) smart scheduling;

(2) orientation visits;

(3) preparation of the patients and parents outside the office;

(4) systematic and in vivo desensitization of the environment; and

(5) teaching self-care when appropriate.


Her 'steps' don't sound too far off from what we already do with our young fearful patients... I enjoyed the article. We should take the time to deliver the best care for these patients without pre-labeling them and dooming them for failure or for just receiving treatment in the OR. Mahalo.

Tuesday, December 27, 2011

The Emergence of the American Academy of Developmental Medicine and Dentistry: Educating Clinicians about the Challenges and Rewards of Treating Pati

Kyung-Hong Cal Kim

The Emergence of the American Academy of Developmental Medicine and Dentistry: Educating Clinicians about the Challenges and Rewards of Treating Patients with Special Health Care Needs

Author: Rick Rader, MD

Pediatric Dentistry Mar/Apr 2007

Key Points
Current obstacles to providing adequate care for patients with neurodevelopmental disorders are
-”Marketing” challenges: lack of interest, curiosity, or excitement
-Lack of formal training: even when medical/dental students wish to treat this population, they feel unprepared to face challenges
-Existing stigma: “mental retardation is not a diagnosis: it’s simply the canvas on which other footnotes are painted.”
-Misinterpretation and misunderstanding of the use of restraints and restraining maneuvers “scare off” clinicians
-Patients with neurodevelopmental disorders unrecognized as “medically underserved” by HRSA despite the fact that its IMU score is significantly lower than the score that defines a group of people as underserved population
-Difficult transition from pediatric care to adult care: need for expansion of medical and dental home across the lifespan

Assessment of Article
This article explains how limited access to basic health care is for patients with neurodevelopmental disorders, and it tries to get to the bottom of it. It showed how frustrating it is for anyone to try to make a difference, but I admire the amount of effort a group of dentists and physicians are making in order to come up with an answer to these health disparities. I agree with author’s statement that clinicians’ hesitance to treat patients with special needs comes from lack of confidence due to lack of training in school rather than issues of reimbursements, and access to health care for that population will significantly improve if medical/dental schools will be required to provide more opportunities to treat patients with special needs. It would be interesting to see how that can be implemented into current curriculum for medical and dental students.

Special Needs and Child Welfare: Healing the Child

Resident Name: Sadler
Article Info: Special Needs and Child Welfare: Healing the Child

Cindy S. Lederman JD

Pediatric Dentistry V29 No. 2 Mar/Apr 07

Main Purpose: Describe shortcomings in the current system of family courts and how it is impacting children.

Key Points:

· Children within the child welfare system have significantly higher rates of physical and emotional problems.

· Decisions regarding the child’s welfare are often made by judges without input for healthcare professionals.

· Dental care is not a priority for these children

· Reviews of cases across the country show that children are frequently not having their physical and mental health needs met

· Access to care was impeded by lack of providers accepting Medicaid.

Assessment of Article: This article was written by a lawyer and essentially outlines how decisions for child in the welfare system are made by overloaded judges who often don’t have enough information about the children. Essentially, the children are not being looked afterward appropriately. The conclusion at the end seems to be that more providers need to take Medicaid but practically that is easier said than done.

Saturday, December 24, 2011

Improving Oral Health For Individuals With Special Health Care Needs

Resident Name: Elliot Chiu

Article Info

Title: Improving Oral Health For Individuals With Special Health Care Needs

Author: James J. Crall, DDS

Journal: Pediatric Dentistry 2007

Main Purpose

To highlight information and issues raised in a keynote address for the AAPD’s Symposium on special needs in 2006.

Key Points

Definition of CSHCN (children with special health care needs): Those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children regularly.

-Examples include asthma (???), ADHD, autism, cognitive disorders, HIV, musculoskeletal disorders, and syndromes.

-Caregivers report dental services to be the second-most needed health care service for their children (behind prescription medications).

-CSHCN have more untreated caries than the general population, however, 18% reported to having no dental coverage.

-10% of general dentists report they treat CSHCN while 95% of pediatric dentists routinely treat this population.

-Solutions to improving oral health care include: increasing the size of the dental workforce, additional training for the dental team, improving reimbursement for dental services.


Asthma is counts as special needs??

This article was a very comprehensive review of oral health in the special needs population. It was a little difficult to follow because the author tried to include so much information in it. It would have helped if the author focused on certain key points that he wanted to address.

Thursday, December 22, 2011

Unmet Dental Needs and Barriers to Care for Children with Significant Special Health Care Needs

Resident’s Name: Jessica Wilson
Article title: Unmet Dental Needs and Barriers to Care for Children with Significant Special Health Care Needs
Author(s): Nelson et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2011. 33:1. 29-38.

To conduct the first known large scale survey of parents of children with special health care needs (CSHCN) and to assess their oral health status, dental needs and perceived barriers to treatment.

A 72 item survey was completed by 1,128 families (30% response rate) with children with special needs across Massachusetts from a convenience sample of patients of 15 urban and rural hospitals, clinics and private practices.

45% of the sample was from the Metro Boston area and the remaining 55% were spread across Western and Central Mass., the North Shore and the South Shore/Cape/Islands. The average age of the children was 10.1 years.

81% of respondents were Caucasian, 67% had private dental insurance, majority of parents had a college degree or higher and 30% of families had an income of over $100,000.

Autism spectrum disorders were the most common (32%) followed by Down syndrome (24%) and cerebral palsy/seizure disorders.

94% of children saw a dentist at least once per year, most of which (66%) saw a pediatric dentist. About a quarter of the children required special accommodations to receive treatment and 21% required intense behavioral intervention (restraint or sedation).

20% of children still currently had unmet dental needs which was more than twice a national census of CSHCN (8%). The authors attribute this discrepancy to the study’s sample of children with more severe/complex special needs.

The most commonly reported problems were caries, crooked teeth, grinding and tarter build-up. Parents most consistently reported 3 major barriers to dental care: “dental care is too expensive”, “hard to find dentist willing to treat my child” and “child’s medical conditions make dental treatment very complicated.” Overall, children with craniofacial disorders and cerebral palsy seemed to be impacted by more barriers whereas children with cystic fibrosis, metabolic disorders and hemophilia were impacted the least. Hispanic children, those from Spanish-speaking families, low income families and those living in central/western Mass had significantly more unmet dental needs.

Key points/Summary:
The children with more involved or medically complex special needs have more dental concerns than the general CSHCN population.

Despite majority of parents having a college degree or higher and higher-than-average income, 20% of the children in this study had unmet dental needs.

Environmental barriers to care were greater in families living in more geographically isolated areas, with lower income and in those who experienced language barriers.

Assessment of Article:
This article provides some interesting information, but nothing too out of the ordinary. These findings seem fairly similar to what I might expect from parents of children without special needs regarding their perceived barriers to access to care. It would be interesting to compare findings with a control sample as well.

Wednesday, December 14, 2011

Over-the-counter whitening agents: a concise review

Kyung-Hong Cal Kim

Over-the-counter whitening agents: a concise review

Author: Demarco FF, Meireles SS, Masotti AS

Oral Health Self-Care Products: Realities and Myths International Symposium, Sep 25-27, 2008, Sao Paulo, Brazil

To evaluate and discuss the current knowledge concerning efficacy, mechanism of action, and legislation of the OTC tooth-bleaching products

-Bleaching, among other procedures in esthetic dentistry, has received increased attention in recent years due to increase concern about appearance and decreased incidence and severity of caries
-Most common beaching procedure dispensed by dentists are supervised home-use of 10% Carbamide Peroxide with custom trays
-The only concentration that received the seal of acceptance by ADA is 9-11% CP
-Proliferation of OTC bleaching products in the US were stimulated by FDA that believed that OTC products could “reduce inequity in the access to the health system, reducing the cost of treatments”
-Most studies currently available regarding OTC bleaching products are short-term evaluations funded by the manufacturers

Key Points:
“Whitening” toothpastes
-Claimed by 50%+ of the currently available toothpastes
-Rarely contain CP or HP
-Contain large quantities of abrasives (alumina, dicalcium phosphate dihydrate, silica) that remove superficial extrinsic stains
-Needs to be moderated in order to prevent excessive wear to the underlying enamel and dentin
-Whitening effect obtained seems not to be clinically significant
-Tooth sensitivity and oral irritation are common side effects

-Low concentration (1.5%) of HP + sodium hexametaphosphate (protects from new stains)
-Potential for oral irritation and tooth hypersensitivity

Whitening dental floss and tooth brushes
-Stain reduction around the interproximal and subgingival areas
-Abrasives (silica) included promotes superficial surface abrasion during application
-When compared to MTB, ETB showed better ability to maintain the whitening effect 6 months after at-home bleaching tx w/ CP

Chewing gum
-Prevent extrinsic tooth stain formation
-Ingredient: sodium hexametaphosphate (4.0-7.5%)
-In one study, gum containing nicotine were more effective in the removal of extrinsic stains than the whitening chewing gum

Paint-on gels
-Barrier free whitening products that present HP or CP in a suspension
-Reduced contact time of the whitening agent with the enamel surface (by dilution or rubbing) makes them ineffective

OTC tray with gel activated by light
-Universal tray adapted by the patient at home
-Manufacturer does not clarify active ingredient
-Light activation DOES NOT increase or accelerate the bleaching process
-Ill-fitting tray potentially can cause oral tissue damage, malocclusion

Whitening strips
-HP (5-14%), 5-60 minutes, 1-2x/day
-10% CP = 3.3% HP
-Increasingly popular in US due to low cost and ease of application

-EU: products containing 0.1-6% HP are safe only when administered under professional supervision
-US (FDA): classifies HP products as OTC products
-US (ADA): OTC products are beneficial, but when used under dentist supervision
-France (FDA): OTC products should be classified as medical devices instead of cosmetics, due to the crescent overuse
-Brazil: All bleaching products are considered to be cosmetics
-Carcinogenicity: High HP concentration may act as a promoter of oral lesions

Assessment of the Article:
According to the article, there are many OTC bleaching products currently available and the number continues to rise due to their popularity. The common theme for description of each product was that due to the composition of the bleaching agent used in those products, they all have potential to do more harm than good, especially if they are not being supervised by dental professionals. OTC bleaching products, even in pediatric dentistry, are the chairside discussion topic we can’t avoid, and if we can’t stop them from using them, we should be well aware of the products available and be prepared to answer questions so that they can make educated choices. Personally, FDA’s claim that availability of OTC bleaching products will be beneficial in reducing inequity in access to health care and cost of treatments is outrageous in that it will lead to unmonitored abuse of bleaching products that will then increase the prevalence of tooth hypersensitivity and even oral cancer.

Effects of bleaching on Restorative Materials.

Resident: Swan
Article Title: Effects of External Bleaching on Restorative Materials: A Review
Authors: El-Murr, et al.
Journal: Journal of the Canadian Dental Association 2011; 77.
Main Purpose: Review the current literature on how bleaching with hydrogen peroxide and carbamide peroxide affects the physical properties of restorative materials.
Methods: Literature review
Main Points:
Amalgam: Several studies have found amalgam restorations treated with HP or CP to have increased metal ion leakage. These values did not exceed the limitations set by the WHO so the authors did not deem this a health hazard. Bleaching's effects on microhardness and surface roughness were also found to be negligible.

Porcelain: In vitro study showed feldspathic porcelain to have rougher surface after 21 days exposure to 10% and 35% CP. Another study showed same, but differentiated between autoglazed and overglazed porcelain (autoglazed wasn't affected.) Recommend barrier to porcelain restorations when bleaching as increased roughness could lead to increased plaque retention. Microhardness have yielded mixed results.

Ormocer (Organically Modified Ceramic): these are a combo of inorganic and organic copolymers designed to improve restorations' properties. Study showed found significant color changes with 10 and 35% CP. Studies show no effect on microhardness or elution.

GIC/ RMGIC: Material affected the most by bleaching in studies. Color, microhardness, and surface roughness were all affected significantly in studies (cracks, pits, softening, change in color). Perhaps due to bubbles mixed into material?

Composite resins: This has been the most extensively studied material regarding bleaching's effects. Many studies have shown potential changes in physical properties of composite after bleaching (color, hardness, porosity), researchers have been unable to demonstrate clinical relevance (amount of change is minute). They recommend further research.

Conclusions: There is a total lack of consensus on the effects of bleaching agents on restorative materials. We should be aware that physical properties of restorations may change, but not necessarily need to be replaced. This will vary with each and every patient. Good info to make patients aware of.

Effectiveness of Nightguard Vital Bleaching with 10% Carbamide Peroxide

Resident Name: Elliot Chiu
Article Info
Title: Effectiveness of Nightguard Vital Bleaching with 10% Carbamide Peroxide
Author: Maria Christina dos Santos Medeiros, MSc
Journal: JCDA 2008

Main Purpose
To evaluate the effectiveness of nightguard bleaching with 10% Carbamide Peroxide.

50 dental students in Brazil were randomly split into 2 groups. The experimental group received Opalescence PF (potassium nitrate and fluoride) 10% carbamide peroxide gel and the control group received a placebo. Trays were custom made for each patient.

Participants were also given a standard toothbrush and toothpaste to standardize abrasive effects and fluoride levels.

Observation for all 4 upper incisors: baseline, 21, 30, 180 days

Key Points
Shades in order of lightness: B1, A1, B2, D2, A2, C1, C2, D4, A3, D3, B3, A3.5, B4, C3, A4, C4

Experimental group

-Median baseline shade was A2, median shade at Day 21 was A1.

-Shade remained for 6mons in 88% of subjects.

-36% reported sensitivity, 92% reported satisfaction

Placebo group

-8% (2/25 subjects) found to have shades 2 units lighter at Day 21

-8% reported sensitivity, and 8% reported satisfaction after treatment

The reports of sensitivity were lower compared to other studies, possibly because this gel by Opalescence contained potassium nitrate and fluoride.

2 people in the placebo group that got whiter teeth were not addressed by the author! They should have found out what they were doing on the side during the study.

Evaluators were calibrated to obtain shades, however, there is inherent subjectivity. How effective would a colorimeter be?

A large factor in shade retention is diet. It would be an interesting study to include it – coffee/wine drinkers, smokers?

Tuesday, December 13, 2011

Tooth Bleaching- A Critical Review of The Biological Aspects

Resident’s Name: Matthew Freitas
Author(s): J.E. Dahl et al.
Journal: Critical Reviews in Oral Biology & Medicine
Year. Volume (number). Page #’s: 2003. 14:4. 292-304.
Major topic: Bleaching

-Review the biological aspects of tooth bleaching, including efficacy and side-effects. In addition, the safety of vital tooth bleaching.

-Intrinsic Stains: high levels of fluoride, tetracycline, developmental disorders, and trauma; usually during the development of the tooth.
-Extrinsic Stains: Coffee, tea, red wine, carrots, oranges, tobacco etc.
-Also, the deposition of secondary dentin due to aging, pulp inflammation, and dentin sclerosis may result in gradual darkening of the teeth.

-Bleaching of discolored, pulpless teeth was first described in 1864

-Tooth bleaching today is based upon hydrogen peroxide, which acts as a strong oxidizing agent through formation of free radicals, reactive oxygen molecules, and anions.
-Other medicaments: carbamide peroxide and sodium perborate.

Tx Techniques:
1. Non-vital Tooth Bleaching (“walking bleach technique”)- A combination of sodium perborate and water or hydrogen peroxide is used. The medicament is placed in the pulp chamber, sealed for 3-7 days, and replaced until acceptable esthetics are achieved. An alternative tx would be removing the coronal restoration and sealing the root canal with glass ionomer, 10% carbamide peroxide is applied by the patient. This eliminates chair time, however there’s more potential for adverse effects (such as cervical root resorption from inflammatory-mediated external resportion).
2. External Tooth Bleaching (at home or in-office)- 1. In-office high concentration of hydrogen peroxide (35-50%) or carbamide peroxide (35-50%), 2. Dentist supervised in-office bleaching trays and carbamide peroxide (35-50%), 3. Dentist provided at home bleaching with carbamide peroxide (5-22%), 4. Over-the-counter bleaching. Tooth sensitivity is the most common adverse side effect and also mucosal irritation. It is recommended that tooth-bleaching agents not be used prior to restorative treatment with resin-based materials because polymerization is inhibited.

Carcinogenicity of Bleaching Agents:
-Based on current studies, hydrogen peroxide was shown to have a weak local carcinogenic-inducing potential. Genotoxic action cannot be excluded, since free radicals form from hydrogen peroxide are capable of attacking DNA.

Tooth Whitening in Children and Adolescents: A Literature Review

Resident’s Name: Jessica Wilson
Article title: Tooth Whitening in Children and Adolescents: A Literature Review
Author(s): S. Lee et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2005. 27(5). 362-368.
Major topic: Bleaching

Review current literature presenting usage trends, side effects, safety concerns and carcinogenesis as well as suggestions for the safe use of whitening agents.

Background: A greater number of pediatric patients are requesting tooth bleaching. In one study, many children as young as 10 reported using white strips on their way to school in the morning. In one study, 32% of about 2,500 children reported dissatisfaction with their tooth color, 19% of parents were dissatisfied with the color of their child’s teeth, whereas only 9% of dentists shared their opinion.
Literature reports 50-60% of patients may develop sensitivity after bleaching. Sensitivity can be treated by reducing exposure time, administering a fluoride treatment and recommending desensitizing toothpaste.

Primary dentition: Although the authors conclude that there are probably no indications for tooth whitening in the primary dentition, others believe it is indicated for those children who report tooth discoloration is “bringing negative attention”. Few clinical studies have been done on minor study subjects, so majority of findings are based on case reports of in vitro studies. In theory, due to the enamel and dentin and relatively larger pulps in primary dentition, increased sensitivity may be expected. This does not seem to be the case. One study reported more complaints from adolescents than 7-11 year-olds.

Safety Considerations: Although, the potential for primary teeth to be at greater risk for demineralization due to their higher concentration of organic material exists, the effect on microhardness of tooth structure is not known. Enamel disintegration and pitting have been reported with improper use of whiteners.
So far, there is inadequate evidence regarding the carcinogenicity of hydrogen peroxide in humans. Researchers who did issue warnings, later retracted them stating they were premature.

Recommendations: Because at-home whiteners have the high potential for overuse/abuse, at-home (especially OTC) whitening is discouraged prior to the age of 14 or 15. Informed consent should be obtained and custom trays should be fabricated. No more than 5mg equivalent of 10% carbamide peroxide should be used per treatment. Parents and teenagers may have unrealistic expectations, yet whitening should not exceed 2 weeks. To prolong the whitening effects, the removal of dye-laden candy, sodas and fruit drinks from the diet is recommended as is whitening toothpaste. Fluoride may be applied as a desensitizing agent after whitening.

Contraindications: dry mouth, enzymatic disorders, respiratory/digestive tract disorders, asthma, allergy to vinyl, hypersensitivity to hydrogen compounds, mouth breathing, unrestored caries, frankly exposed roots, broken teeth, severe enamel erosion (bulimia), parafunctional grinding, poor oral hygiene.

Assessment of Article:
This article was full of information. I am not sure how I personally feel about administering bleaching agents to young teenagers, but it is certainly going to be requested of us out in private practice. Perhaps the perceived need for bleaching can work to our advantage as a motivator for better oral hygiene and diet!

The Shear Bond Strength of Aceton and Ethanol-based Bonding Agents to Bleached Teeth.

Resident Name: Sadler
Article Info: The Shear Bond Strength of Aceton and Ethanol-based Bonding Agents to Bleached Teeth.

Jorge H. Caceda DDS, MPH, MS et al.

Pediatric Dentistry 28:6 2006

Main Purpose: Evaluate bond strength of composite in bleached/unbleached teeth and also between acetone or ethanol based adhesives.

Methods: 40 recently extracted posterior teeth were used for analysis. 32 used for bond strength analysis and 8 for microscopic analysis. Teeth were randomly assigned to bleached or unbleached groups. Teeth were bleached with a light activated 35% hydrogen peroxide solution and soaked in saline for 24 hours. All teeth were then acid etched and rinsed. Then either a acetone or ethanol based adhesive was placed and cured. Composite was then placed and cured and strength was analyzed.

Key Points:

· No statistically significant difference was found between the two bonding agents.

· Bond strength was found to be weaker in bleached teeth than non-bleached teeth.

· SEM of bleached teeth showed sparse and poorly defined adhesive penetration.

Assessment of Article: Very easy to understand article with clear findings. I know that bleaching is becoming increasingly popular and even in a pediatric practice bleaching will be a part of the services patients will want. I think the study was well done but I really don’t like the 24 hour period used. Even the authors admit that further investigation into bonding at 2-3 weeks would be needed. I would take from the article to not do any fillings in the same appointment as a bleaching but I doubt this happens often.