Tuesday, January 31, 2012

Recurrence of Early Childhood Caries after Comprehensive Treatment with General Anesthesia and Follow-up

Resident’s Name: Jessica Wilson
Article title: Recurrence of Early Childhood Caries after Comprehensive Treatment with General Anesthesia and Follow-up
Author(s): Foster et al.
Journal: Journal of Dentistry for Children
Year. Volume (number). Page #’s: 2006. 73:1. 25-30.

To determine the likelihood of new caries in children treated under GA for EEC, and if attendance of immediate follow-up can prevent relapse.

All patients with ECC that had been scheduled for treatment under GA at Women and Children’s Hospital of Buffalo in 2000- were reviewed and were included if they received at least one exam within the 6-24 month postoperative period. It was stated that the children received and “aggressive treatment approach” and included OHI and diet counseling.

193 of the 448 patients fit the criteria and ranged from the ages of 19 and 60 months.
Only 76 (39%) of patients returned for their 2 week post-op appointment, but 90% returned for at least one of their scheduled recare visits. 2/3 of the patients also showed for an emergency walk-in appointment for the loss of a restoration or pain.
Within 2 years, 103 (53%) had new carious lesions. Those children who failed their post-op appointment were more likely to relapse (34% vs. 19%), especially in the primary dentition, however, this was not significant.

Assessment of Article:
This article had some interesting points. A previous study found that 46% of their patients showed for a 1 week post-op appointments and the authors speculate that the immediacy may be responsible. Comparing our no show rates from our 1 month-post op appointments to our now 1 week post-op appointments may be a good future study.

Dental Surgery under General Anesthesia for Preschool Patient’s With Orofacial Clefts

Resident’s Name: Matthew Freitas

Author(s): Jeffrey M. Karp

Journal: JADA

Year. Volume (number). Page #’s: 2009. 35:1. 426-431.

Major topic: Hospital Dentistry


-Preschool children with orofacial clefts are prone to develop early childhood caries.

-Studies have cited the presence of enamel defects, high mutans streptococci and lactobacilli counts, deficient oral hygiene practices and slow oral food clearance times as contributing factors for dental caries in these patients.

-The use of infant orthopedic appliances and prolonged bottle feedings, have also been implicated in the establishment of ECC in infancy.


-The purpose of this article was to describe the hospital care of 72 patients with orofacial clefts (range=2-5 years old) and ECC treated in 15 total dental surgeries under general anesthesia.


-Moderate and deep forms of sedation may be contraindicated for these patients, because airway stability and resuscitation efforts in a medical emergency could be jeopardized by their head and neck anomalies. For these patients, dental surgery under general anesthesia is an excellent option for treatment of early childhood caries.

-Maintenance of arch length, control of the vertical dimension of occlusion, and stable anchorage for orthodontic appliances are additional reasons to restore carious teeth with intracoronal restorations or stainless steel crowns.

-Tooth extraction in the cleft site can result in reduced bone volume and widened cleft widths before alveolar bone grafting in the preadolescent period.

-Orotracheal intubation of cleft patients during dental surgery makes the performance of dental procedures very difficult, as the ET tube occupies much of the oral working space and causes longer surgical times.

Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Resident Name: Sadler
Article Info: Postoperative Pain and Other Sequelae of Dental Rehabilitations Performed on Children Under General Anesthesia

Howard L. Needleman DMD

Pediatric Dentistry V30 No. 2 Mar/Apr 08

Main Purpose: Describe postoperative pain following treatment under GA

Methods: 97 healthy kids were treated under a standardized GA protocol. Parents used a FLACC (Face, Legs, Activity, Crying, Consolability) score along with a graded faces scale to determine pain levels in the children. Patients were called for two days to make sure the questionare was being filled out and then collected at a 1 week post op appointment. No local was used for extractions.

Key Points:

· 95% of children reported postoperative pain.

· Pain scores were highest in the recovery area and tended to increase with the number of procedures performed

· Extractions were also associated with postoperative pain

· A traumatic intubation was also associated with a sore throat

· Other sequalae included need for pain medication, sleepiness, sleeplessness, and agitation with agitation and need for post op medication being the most common

· Symptoms decreased greatly after two days and were virtually gone by four days.

· Longer treatment times were associated with increased sleepiness

· Children aged 4 or older were more likely to have post operative pain

Assessment of Article: This was a well discussed and thorough article. My main take home message was that the authors say that the sedative effect of GA is adequate for extractions and local is not needed however there are other studies that contradict this finding.

Pediatric Condition associated with compromised airway

Pediatric Conditions associated with Compromised Airway - Part I Congenital
Nicolas S. Wage, DDS; Suher Baker, DMD, BDS,MS; Heddie O. Sedano, DDS, Dr. Odont

Pediatric Dentistry V 31/No 3 May/Jun 09

Abstract: A discussion of congenital conditions which are characterized by potentially difficult airway management.

Discussion: Respiratory complications are the leading cause of pediatric anesthetic related morbidity and mortality. A thorough evaluation of the patients airway and medical conditions which may lead to airway obstruction must be evaluated prior to any decisions on medical care and treatment. Additionally, the anatomy of a pediatric airway is much different than an adult and may lead to more difficult airway maintenance. Pediatric respiratory systems require higher levels of O2 consumption, higher ventilation and limited reserve.

Congenital conditions associated with a compromised airway and a few notes... (Please read article or look up conditions for more information -I'm just noting airway and oral manifestations)

Robin sequence: cleft palate, micrognathia, glossoptsosis, downward displacement of tongue. Cyanotic attacks, respiratory difficulty, little support of tongue musculature.

Treacher Collins: Mandibular condyle and coronoid process may have sever hypoplasia, malformation, or even aplasia. Sleep apnea common, clefting in 35%. Upper airway obstruction common

Crouzon: Maxillary hypoplasia, mandibular prognathism, high arch, v-shaped palate. Cleft lip and or palate. Chronic tonsillar herniation.

Apert: Craniosynostosis, midface malformations and symmetric syndactyly. Midface retruded and hypoplastic. Cleft palate, reduction of nasopharynx, respiratory complications, cartilagenous trachea and tracheal ring abnormalities.

Goldenhar: most complex clinical manifestations of the aculoauriculovertebral spectrum. Maxillary, temporal and malar bones are reduced in size and flattened. Aplasia or hypoplasia of the mandibular ramus and condyle. After these patients undergo TMJ surgery airway management is difficult. TEF are common. Hypoplastic tongues, cleft lip and palate and VPI.

Down Syndrome: mandibular prognathism, midface hypoplasia. Open mouth, protruding tongue, enlarged tongue, tonsils and adenoids. Tracheal intubation may lead to subglottic stenosis.

Klippel-Feil: Cervical vertebral fusion, short neck, limitation of head movement. Spina bifida, spnial canal stenosis, scoliosis, atlanto-occipital fusion, cleft vertebrae and hemivertebrae.

Beckwith-Wiedemann: Exopthalmos, macroglossia and gigantism. Alveolar hypoventilation at birth leading to cor pulmonale or right sided heart failure. Primary cause of airway obstruction is large protuberant tongue.

Cherubism: Expansion of the posterior mandible, fullness of face. Gingival enlargement preventing jaw closure. Airway obstruction has be a significant cause of morbidity when tongue is displaced.

Congenital hypothroidism: Obesity, lethargy, swelling of face, bradycardia and hypothermia. Fluid accumulation.

Cri du Chat: severe physical and cognitive growth retardation, feeding problems, microcephaly, micrognathia and facial asymmetry. Bifid uvula, dental malocclusion, short neck, scoliosis, hemivertebrae.

Von Recklinghausen: Neurofibromas found in organs. Neoplasms in the scalp, cheek, neck and oral cavity. Tongue lesions can cause gross tongue enlargement. VPI also noted.

Hurler: Lips enlarged and mouth open till age 3. Hyperplastic adenoids and constricted nasopharynx. Upper airway obstruction from epiglottic, tonsillar and tracheal thickening. Ramus is reduced and limited movement of the TMJ

Hunter: Airway obstruction due to macroglossia, pharyngeal deformation, short immobile neck, mucous nasal discharge, anatomical deformation and narrowing trachea.

Pompe: Most patients rely on artificial ventilation due to multisystem organ dysfunction. Swallowing is difficult with a protruded tongue. Laryngeal nerve paralysis and feeding difficulties may lead to aspiration.

Osteogenesis Imperfecta: Due to bone fractures patients should be repositioned carefully.

Moebius: Limitation of eye movement, facial expression, feeding and swallowing difficulties, choking predisposition, drooling, cleft palate and speech difficulties. Upper midfacial protrusion, hypoplastic mandible and tongue.

Saethre-Chotzen: High arch palate, malocclusion, supplemental teeth and cleft palate.

Rubenstein-Taybi - High arched palate, micrognathia, bifid uvula, palatal clefting, bifid tongue, macroglossia and natal teeth.

De Lange: Small nose with inverted nostrils depressed nasal bridge, high arch palate, short muscular neck and micrognathia.

In Conclusion...Many of these syndromes pose a profound effect of airway management during sedation, induction and maintenance of GA. A controlled inpatient setting is most appropriate. Caution should be used for oral sedation with out IV access and advanced monitoring. Moderate sedation is risky and should be avoided.

Enjoyed the article as we've seen some of these syndromes this year with our Craniofacial clinic.

Wednesday, January 25, 2012

Treatment of Large Jaw Bone Cyst in Children

Resident’s Name: Jessica Wilson
Article title: Treatment of Large Jaw Bone Cyst in Children
Author(s): Sun et al.
Journal: Journal of Dentistry for Children
Year. Volume (number). Page #’s: 2009.76:3. 217-222.

Radicular cysts- located around roots and originate from epithelial reminants of perio ligament as a result of inflammation (caries/pulpal necrosis). It is the most common type of cyst in jaw (78%), but rare in primary dentition. When it does occur in the primary dentition. it usually occurs around the primary mandibular molars.
Dentigerous cyst- encloses the crown of an unerupted tooth and is caused by an alteration in the reduced enamel epithelium which results in fluid accumulation. 2 types: developmental and inflammatory.

Case 1:
A 6 yo healthy female presents with a painful swelling in the primary mandibular left molar region where she had previously received several pulp treatments. She displayed buccal bone expansion, facial asymmetry, and her pano showed a unilocular 2 x 2 cm diameter radiolucent lesion under #K displacing the second premolar to the mandible’s lower border. #K and L were extracted and a bony biopsy and decompression were performed under local anesthesia. A removable space maintainer with obturator was placed to keep the wound open and the patient was taught to irrigate the cavity after every meal. The obturator was adjusted monthly and was removed after the second premolar erupted normally. There was no recurrence after 2 years follow-up.

Case 2:
An 8.5 yo female presented for a painless swelling in the primary mandibular right molar region. EOE: diffuse, non-tender, hard bony sewlling, buccal expansion and grossly decayed #T with previous pulp treatment. The pano revealed a 3 x 2 cm unilocular radiolucent lesion enclosing the crown of the partially formed second premolar. The diagnosis was a radicular cyst associated with a failed pulp treatment. The cyst was decompressed by the removal of the primary second molar and an obturator similar to the one described above was placed. The patient was monitored at 3 month recalls and the obturator was removed once the cyst had shrunk to less than 1cm in diameter. The premolar erupted uneventfully 1 year later.

Case 3:
A 7 yo healthy female presented with swelling in the primary mandibular left molar region with lower lip parasthesia. #K had previous pulp treatment. A 4.5 x 2 cm diameter lesion was seen on the pano and the second premolar was severely displaced below #19. Similar treatment as described in the previous cases was performed and a dentigerous cyst was diagnosed. After 6 months, the premolar was still severely displaced and upside down and the cyst remained unchanged. Therefore, under GA, #19 was extracted to gain access to #20, #20 was removed, cyst enucleation was performed and #19 was immediately re-implanted. The molar showed a PA radiolucency 6 months later and endo treatment was performed. There was no recurrence after 4 years.

Case 4:
3 yo female presented with mandibular left swelling, but no caries were detected. Her pano showed a 5 x 2.5 cm radiolucent lesion below #K which contained a severely displaced #19. Under GA, the cyst was decompressed and a biopsy was completed. After 6 months #19 had continued to erupt, but a 1 year recall the cyst had reurred and a second surgery was completed and a dentigerous cyst was confirmed. The premolar germs were found to be malpositioned and will require further treatment in future.

Congenital Ranula: A Case Report

Authors: Cavalancante, Ana Sueli, PHD, et. al.

Journal: Journal of Dentistry for Children-76:1, 2009

Purpose: To report a case of bilateral swelling on the floor of the mouth of a 7-month-old patient.

Key Points:
-A seven month old female patients presented with chief complaint that she was born without a tongue that was visible to her parents and had difficulty suckling, with two previously unsuccessful drainage attempts by ENT, as well as antibiotic treatment for swelling. This patient in particular was seen in an oral disease clinic in Brasil after unsuccessful resolution by the ENT.

-Intraoral examination revealed swelling of the floor of the mouth, causing superior and posterior displacement of the tongue-- Patient was asymptomatic

-Lesion was marsupialized, with a brown mucous drainage that resulted (in article, it said clear liquid means lesion relatively new, brown or darker, or amber, means mild to severe inflammation)

-Histology was the following: fragments of fibrous connective tissues with pseudo-stratified columnar epithelial or stratified squamous and non-keratinized eptihelium in some areas. There were areas with mucoid material also, and mononucluear inflammatory infiltrate.

-Final Diagnosis: Mucous Retention Cyst

-Patient returned at age five with mom's concern that an opening on the floor of the mouth remained that made the child uncomfortable but mother did not want corrective surgery

-Differential Diagnosis of swelling of the mouth's floor in neonates: lymphatic malformations, teratoma, dermoid cyst, thyroglossal duct cyst

-Treatment of ranulas include: incision and drainage, marsupialization, micromarsupialization, excision of the lesion with or without removal of the ispilateral salivary gland, cryosurgery, carbon dioxide laser excision, an the use of sclerosing agents (OK-432), and homotoxiological remedies
-- no consensus on what is the best tx. option according to the article

-Different recommendations in the research were discussed; options being to excise the sublingual gland to avoid high recurrence rate after marsupialization. Some recommended before it recurs, some after it recurs. There is a change of damage to the lingual nerve when removing the submandibular gland. Plunging ranulas should always have submandibular gland removed.

-Spontaneous resolution may occur in children and 5 month follow ups are recommended

It was mentioned in the article that a congenital ranula can recur if spontaneously resolved due to rupture during feeding--important for us to know in practice

-It is important to remember the color of the cystic fluid and tell us if lesion is older or newer

-In some extreme cases, the ranula size can cause a posterior displacement of tongue, as well as difficulty in speaking and swallowing.

-Overall, the correct diagnosis and timely treatment of congenital ranulas affecting the floor of the mouth can improve the quality of life of the child and parent, and also prevent breathing and feeding problems.

Final Assessment: According to the author, it is extremely important to raise awareness of the dental surgeon's role in diagnosing and treating ranulas, which are often treated by medical surgeons only. I would have to completely agree. Somtimes ranulas can be very subtle in their presentation, always check the floor of the mouth in an initial examination to see if there are any unusual findings to note "early on" so then they can be closely monitored.

A Nasopalatine Duct Cyst in 7 yr old child

Resident: Swan
Article Title: A Nasopalatine Duct Cyst in a 7-year old Child
Authors: Scolozzi, et al.
Journal: Pediatric Dentistry, V30, No 6, 2008
Main Purpose: Describe a rare developmental cyst in a 7 year old child; its etiology, diagnosis, treatment.

Background: Nasopalatine Duct Cyst (NPDC) is most common of nonodontogenic cysts (74%). Occurs in nasopalatine canal, believed to develop from embryonic epithelial residues present between embryo's nasal and oral cavities. Etiology is unknown. Usually asymptomatic unless infected. Most commonly reported clinical symptom is swellling, usually in the midline of anterior palate. Discharge may be mucoid or purulent with a salty or foul taste. On x-ray, appears as well-defined radiolucency, symmetrical, round.  Considered very rare in children. Average age of pt in very large study was 43 years.

Case Report:  7 yr old Libyan boy referred by dentist to OMS service in Geneva, Switzerland for examination of slow-growing mass on anterior palate. No pain or drainage present. Mass discovered while investigating malpositioned permanent maxillary incisors. Exam revealed purplish-blue fluctuant swelling of anterior hard palate, 2X2 cm. Permanent R/L maxillary central incisors were snow-plowing and in anterior crossbite. Vital, not percussion tender. Pano revealed large, well circumsribed, symmetrical radiolucency displacing roots of teeth. Roots were not resorbed. Cyst was treated under GA (wholly enucleated--all involved tissue, hard and soft, is removed).
Histology of cyst wall revealed fibrous wall lined by stratified squamous epithelium. 2 year follow up showed no recurrence.

Discussion: This cyst should be on our differential with anterior palatal swellings, although it is extremely rare in kids.

Conservative Surgical Treatment of an Aggressive Calcifying Cystic Odontogenic Maxillary Tumor in the Young Permanent Dentition

Kyung-Hong Cal KIm

Conservative Surgical Treatment of an Aggressive Calcifying Cystic Odontogenic Maxillary Tumor in the Young Permanent Dentition

Authors: Sakai VT, Gomes do Couto Filho CE, Silveira Moretti AB, Costa Pereira AA, Costa Hanemann JA, Alves Duque J

Pediatric Dentistry May/Jun 11

-A rare, benign cystic neoplasm of odontogenic origin characterized by an ameloblastoma-like epithelium with ghost cells that may calcify
-1-2% of all benign odontogenic lesions
-4-76-year-old with no gender predilection
-Mostly in the region of canines and premolars
-In 1/3 of cases an unerupted tooth is associated with the lesion
-Unilocular or multilocular radiolucent area, well circumscribed or poorly defined radiopaque margins with different amounts of associated radiopaque material
-Resorbed and divergently displaced roots of adjacent teeth
-Aberrant epithelial cells without nuclei: “ghost cells”
-Cement-like or dentin-like tissue in the cystic capsule produced by mesenchymal cells
-Depends on the lesion’s localization and histological type
-Cystic variant: enucleation with curettage
-Neoplastic variant: complete excision (recurrence is frequent)

-A 12-year-old female w/ “gingival swelling”
-Diffuse volumetric swelling that had increased in size in the region of permanent maxillary right premolars and molars
-Discrete facial asymmetry due to a swelling in the middle third of the face
-Firm swelling, unulcerated mucosa of normal appearance that extended from #3 to #6, missing #5
-Brownish liquid content from aspiration
-Unilocular radiolucent area surrounded by a discrete radiopaque halo and circumscribing radiopaque masses, associated with an unerupted #5
-Divergently displaced roots of #4,6, expanded buccal cortical bone
-Large extension of the lesion involved nearly the entire maxillary right sinus and extended into the orbital floor
-Differential Dx: calcifying cystic odontogenic tumor, calcifying epithelial odontogenic tumor, adenomatoid odontogenic tumor
-Incisional biopsy under local anesthesia
-Cycstic marsupialization and placement of an acrylic resin tube for drainage 4 months later
-Surgical extraction of #5 after significant regression of the lesion was noted 2 years after initiation of treatment
-No recurrence after 4 months

Trabecular Juvenile Ossifying Fibroma with Aneurysmal Bone Cyst: A Rare Presentation

Resident: Cho

Author: Silva et al.

Journal: Pediatric Dentistry 33:5, 2011

Type: Case Report

Main Purpose: Report a case of trabecular juvenile ossifying fibroma associated with an aneurysmal bone cyst

Key Points: Juvenile ossifying fibroma is a variant of ossifying fibroma. It is an uncommon benign neoplasm that arises within the craniofacial bones. Usually asymptomatic, high rates of recurrence, and first clinical presentation is an extraoral mandibular swelling. The juvenile form is more aggressive than the adult form. 2 variants: psammomatoid pattern (involves bones of orbit and paranasal sinuses) and trabecular pattern (involves jaw, predominately the maxilla). The aneurysmal bone cyst can occur with the juvenile ossifying fibroma.

Case Report: 9 year old Caucasian female presented with left facial swelling that had been developing for approximately 6 months. The lesion was asymptomatic and had rapidly increased in size since it was first noticed. Intraoral examination revealed expansion of the left buccal cortical bone, which was firm and painless to palpation and extended from the maxillary left canine to the maxillary left second molar. Panoramic examination showed radiodense lesion with undefined limits. Incisional biopsy performed. Dx: trabecular juvenile ossifying fibroma with central aneurysmal bone cyst. Tx: conservative local excision of lesion. Three years later, patient returned again with recurrence of the lesion in the same area. Tx: curettage of entire lesion under GA. After 6 months of follow up, no recurrence of the lesion.

Tuesday, January 24, 2012

Treatment of a Large Dentigerous Cyst in a Child

Resident Name: Sadler
Article Info: Treatment of a Large Dentigerous Cyst in a Child

Rafaela Scariot DDS et al

Journal of Dentistry for Children-78:2,2011

Main Purpose: Case report of treatment of a dentigerous cyst in an 11 year old boy

Key Points:

· Dentigerous cyst encloses the crown of an unerupted tooth and is generally attached to the tooth’s neck

· They most commonly occur in teenagers and it is believed they arise from the tooth follicle

· 11 year old boy was referred to OMFS in Curitiba, Brazil.

· Med history was non contributory and no pain was reported

· Facial asymmetry was noted due to fluctuant swelling of right side of the face

· Pano taken and shows 6mm radiolucency including the crowns of an unerupted canine, lateral, and central.

· Permanent lateral was 90 degress to occlusal

· Local anesthesia was given and needle aspiration was performed and a drain was sutured in place

· The cyst shrank but did not disappear and teeth moved but did not erupt.

· Remaining cyst was removed along with problematic teeth under GA

· 2 years following the procedure the cyst has not recurred and the patient is symptom free

· He was made a RPD and has a treatment plan for dental implants.

Assessment of Article: Very good article and description. The authors suggest that treatment for these cysts should include drainage and decompression to shrink the cyst away from vital structures and make for a less dramatic resection. Research cited states that shrinkage occurs at an average of 81% which is pretty dramatic. Like we talked about last time it is always important for us to carefully examine our panos to make sure that we catch these cysts in growing teenagers.

Conservative Management of a Large Dentigerous Cyst in a 6-year-old Girl: A Case Report

Resident’s Name: Matthew Freitas

Author(s): E. Bozdogan et al

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2010. 78:3. 163-167.

Major topic: Soft Tissue/Oral Pathology


-Dentigerous cysts are benign odontogenic cysts associated with the crown’s of erupting permanent teeth. They enclose the crown of the tooth at the CEJ, expand by growth of the follicle and typically inhibit the eruption of the tooth or surrounding teeth.

-The teeth most often associated with DCs are mandibular molars, max canines and mandibular premolars.

-These cysts are often asymptomatic and painless.

-Treatment: enucleation or marsupialization (in cases associated with displaced and unerupted teeth).

Case Report:

-6 year old girl referred to a pediatric dentist in Turkey with the complaint of painless facial swelling in her left posterior mandibular region that began 8 weeks earlier. Intraoral examination revealed swelling in the region of the left primary second molar. The left primary first molar was previously extracted due to a periapical infection. A panaromic examination showed a large, well-defined unilocular area from the mandibular left canine tooth to the mandibular first molar tooth. A CT image was obtained due to the large size of the lesion. CT imaging showed a well-defined lesion in the mandibular left region surrounding the unerupted second premolar’s crown and partially surrounding the unerupted first premolar’s crown. The root apices of these teeth were open and the teeth were displaced. No signs of root resorption were present in the adjacent teeth. The primary mandibular left second molar was extracted, and the marsupialization technique was performed by an oral surgeon. A biopsy tissue sample was taken and then a silicon tube was installed to drain the intracystic pressure. Results from the biopsy confirmed the diagnosis of a DC. At 21 months follow-up the radiographic radiolucency had decreased and the canine and premolars showed further eruption.


-Conservative treatment of a DC depends on the size and location of the cyst, patient age, affected dentition, and cyst’s relationship with surrounding vital structures. Marsupialization is indicated for children and adolescents to preserve the teeth and promote the eruption of the dislocated tooth associated with the cystic lesion. Marsupialization, by relieving intracystic pressure through the creation of an accessory cavity, maintains the impacted tooth in the cystic cavity and promotes eruption.