Wednesday, October 31, 2012

Dentoalveolar Trauma in a Patient With Chronic Idiopathic Thrombocytopenic Pupura: A Case Report

Title: Dentoalveolar Trauma in a Patient With Chronic Idiopathic Thrombocytopenic Pupura: A Case Report
Resident: Matthew Freitas
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. 26:4. 352-354.

-Idiopathic thrombocytopenic pupura (ITP) is a hemorrhagic disorder that causes an abnormal increase in the destruction of circulating platelets. It is the most common cause of thrombocytopenia in childhood. Chronic ITP is commonly due to autoantibodies directed against glycoproteins of platelets. The main danger in treating patients with ITP is hemorrhage. Prior to surgery, intravenous gamma globulin (IVIg) is recommended for children with platelet counts below 20,000. Elective surgery should be performed with a platelet count of 50,000.

Case Report:
-13 yr old boy with chronic ITP sustained traumatic labial luxation of teeth #24 and #25 with partial alveolar fracture. Bleeding was controlled with gauze and pressure. It was determined to reposition his teeth and alveolar plate under general anesthesia. Before surgery, intravenous immunoglobulin was given for 2 days, which rose the patient’s platelet count from 15,000 to 70,000. Displaced alveolus and teeth were then repositioned and splinted under general anesthesia, using a resin composite split to the labial of all lower incisors. Healing was uneventful and the splint was removed after 2 weeks. The patient was kept on a 3 month recall and both incisors were confirmed non-vital and endodontic treatment was performed.

-Platelets >50,000: little clinical bleeding is expected during minimally invasive dental treatment.
-Platelets <30,000: bleeding following dental procedures may be difficult to control. Regional anesthesia, such as a mandibular block is contraindicated.
**It is important when treating one of our patients with a bleeding disorder to work closely with the patient’s physician or hematologist.

Resident: Mackenzie Craik

Article: Dental Care of the Pediatric Cancer Patient

Publication: Pediatric Dentistry 26:1, 2004.

Key Points: 
-Cancer is the leading cause of disease-related fatalities for children between 0 and 14 years of age in the United States, affecting approximately 1 in 7,000 children every year.
-Acute lymphoid leukemia (ALL) is the most common malignancy (24% of all childhood malignancies), followed by central nervous system (CNS) tumors (22%) and sarcomas.
-The dental consultation on a newly diagnosed patient should be done at once so that
enough time is available for care to be completed before the cancer therapy starts.
-Particular attention should be paid to patients with coagulation disorders and liver tumors or liver dysfunction because they are at high risk for prolonged postoperative bleeding.
-There is evidence that patients who do intensive oral care have a reduced risk of developing moderate/severe mucositis, without causing an increase in septicemia and infections in the oral cavity.
-When there is time prior to the initiation of cancer therapy, dental scaling and prophylaxis should be done, defective restorations repaired and teeth with sharp edges

-The key to success in maintaining a healthy oral cavity during cancer therapy is patient compliance. 
-It is vital to educate the caretaker and child about the importance of oral care to minimize discomfort and maximize the chances for a successful outcome. 
-Discussion should also include the self canceling effects of indulging the child with
unhealthy foods, the potential cariogenicity of pediatric medications and nutritional supplements, and late effects of the conditioning regimen on the craniofacial growth and
dental development. 
-It is important for the pediatric dentist to realize that these issues are rarely discussed by the physicians and nurses involved in the patient’s care. 
-Furthermore, the participation of a pediatric dentist in the hematology/oncology team is of irrefutable importance.

Analysis: I thought that this was a good literature review of what is the proper course of action to proceed with in child that has cancer.  I thought it gave a broad overview.  Difficult to analyze since it wasn’t really a study.


Resident: Elliot Chiu

-Widespread use of ABs has lead to resistance to drugs
-Conservative use of ABs is recommended
-Intraoral lacerations contaminated by extrinsic bacteria, open fractures, and joint injury have increased risk of infection and should be covered with ABs
-AB therapy is usually not indicated if a dental infection is contained within the pulpal tissue or the immediately surrounding tissue (with no fever or facial swelling)
-Facial swelling: treatment may consist of treating or extracting the tooth with AB coverage or prescribe ABs for several days to contain the spread of infection
-Topical and systemic ABs are indicated for avulsions
-Females taking oral contraceptives must be advised to use additional techniques for at least 1 week beyond the last dose.

-Bacteremia is anticipated following invasive dental procedures
-Infective endocarditis is an uncommon but life-threatening complication resulting from bacteremia
1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
2. Previous IE
3. Congenital heart disease
     a. Unrepaired cyanotic CHD
     b. Completely repaired defect with prosthetic material for 6months after procedure
     c. Repaird CHD with residual defects
4. Cardiac transplant pts who develop cardiac valvulopathy
-All dental procedures that involve manipulation of gingival tissue
-LA through non-infected tissue, x-rays, placement of removable prosthodontic or orthodontic appliances, placement of brackets, shedding of deciduous teeth, bleeding from trauma to the lips or oral mucosa
-Amoxicillin 50mg/kg
-Ampicillin or Cefazolin 50mg/kg IV/IM
-Clindamycin 20mg/kg or Azithromycin/Clarithromycin 15mg/kg
-Clindamycin 20mg/kg 20mg/kg IV/IM

Handbook Chapter 21-Hematologic Disorders

Handbook Chapter 21-Hematologic Disorders

  • Reduction in red cell volume
  • Diagnosed with HX (clinical and family), Exam, and lab work
  • Anemias resulting from inadequate red cell or hemoglobin production: congenital red cell anemia; anemia of chronic renal diseas; anemia of infection, inflammation and cancer
  • Anemias resulting from incresed destruction of red cells: intrinsic abnormality; enzymatic defects; defects in hemoglobin synthesis
  • Anemias from extracellular abnormalities: infections, autoimmune, transufision
Dental considerations-Low risk-treat as normal; High risk-consult with MD, minimize stress, consider tx in hospital setting

Bleeding Disorders
  • Congential: Hemophilia A and B, von willebrand disease, absence of clotting factors
  • Acquired-Liver disease, Vit k deficiency, drug induced (heparin)
  • Thrombocytopenia-bone marrow failure (leukemia, metastatic cancer, vitamin b12 deficiency, drug induced)
  • Peripheral platelet destruction- Thiazide diaretics, quinidine, gold salts, sulfonamides
  • Platelet dysfunction-Drug induced (aspirin, ibuprofen, naprosyn), Congential (vol Willenbrand Disease), Secondary complication (uremia)
  • Hypersplenism-hypertension, cancer
  • ITP-Immune thrombocytopenic purpura
  • TTP-Thrombic thrombocytopenic purpura
Oral Evaluation

  • Detailed history-Nose bleeds, menstral hemorrage, easy bruising, family hx of disorderes
  • Physical exam-excessive bruising or spontaneous bleeding
  • Lab screening-PT, PTT, platelet count
  • Consult with MD
  • Low risk-Treat as normal
  • Moderate-consult with MD and treat with current lab values known and adjust according especially for EXT
  • High-consider tx in hospital setting, nasoendotracheal intubation may be contraidicated

AAPD Handbook Chapter 18 - Childhood Cancer

Resident: Jeff Higbee

AAPD Handbook Ch. 18 – Childhood Cancer

Childhood cancer is rare representing less than 1% of new cancer dx
Symptoms are usually non-specific
- Unusual mass or swelling
- Unexplained paleness or loss of energy
- Sudden tendency to bruise
- Persistent, localized pain
- Prolonged fever or illness
- Frequent headaches often with vomiting
- Sudden eye or vision changes
- Excessive, rapid weight loss

Common Cancers in Children 0-19 yrs
- Leukemia

                - Represents 31% of cancers before age 15

                - Mostly in children ages 1-4

                - Overall rates are higher among white kids

                - Survival for ALL is about 90% and 55% for AML (2004)

                - Little is known about the cause of ALL

 -CNS Cancers

                - Represents 21.3% of cancers of childhood and adolescence

                - Leading cause of cancer death among kids 1-5


                -3rd most common form of childhood cancer

                - Hodgkin’s and non-Hodgkin’s

                - In 2005 survival for HL was 94% and NHL 85%

 - Sympathetic Nervous System Tumors

                - Arise from neural crest tissue

                - 7.8% of cancers in children less than 15

                - 97% are neuroblastomas – most common malignancy 1st year of life

- Soft Tissue Sarcoma

                - 7.4% of cancers in children younger than 20 yrs

                - Rhabdomyocarcoma is the most common form

                - 5 yr survival rate 66%

- Renal Tumors

                - Wilm’s tumor which occurs most commonly before age 5

- Malignant Bone Tumors

                - Osteocarcoma (56%)

                - Ewing Sarcoma (34%)

                - 5 yr survival 71%

Oral Complications of Chemotherapy and Radiotherapy
- Mucositits
- Secondary Infections
- Xerostomia
- Neurotoxicity
- Bleeding
- Mucosal/muscular fibrosis
- Post radiation osteonecrosis
- Soft tissue necrosis
- Craniofacial and dental development problems
- Oral graft vs host disease

 Oral and Dental Management
- stabilize and eliminate existing and potential sources of oral infection and local irritants before cancer tx
- Should use regular, 2-3 times a day, tooth brushing
- Chlorhexidine use and flossing daily
- Encourage non-cariogenic foods
- Fluoride toothpaste
- Daily oral physical therapy for those that will receive radiation to the face – to prevent trismus
- Stress the importance of optimal oral care

Hematological Parameters

- Absolute neutrophil count

                 > 1,000/mm – no need for supplemental antibiotics

                < 1,000/mm – defer elective tx until ANC rises

- Platelets

                > 75,000/mm – no additional support needed

                < 75,000/mm – consult physician before dental care

Dental Procedures
- Ideally dental care should be done before therapy starts
- Infections, extractions, scaling, carious teeth, RCT, replacement of faulty restorations
- RCT 1 week before tx
- Remove orthodontic appliances unless they are smooth well fitting
- Extractions should be done at least 7-10 days prior to cancer tx
- Be careful with extractions or biopsies in areas of previously irradiated areas
- Defer all elective tx

Tuesday, October 30, 2012

Infection from an Exfoliating Primary Tooth in a Child with Severe Neutropenia: A Case Report

Resident: Derek Nobrega
Title: Infection from an Exfoliating Primary Tooth in a Child with Severe Neutropenia: A Case Report
Authors: Catherine Hong, BDS, MS; Michael T. Brennan, DDS, MHS; Joel Kaplan, DO, MPH; Peter B. Lockhart, DDS
Journal: Pediatric Dentistry. 2012. 34 (1): 51-53

Main Purpose: To describe the case of a child with acute lymphoblastic leukemia who presented with fever, trismus, and submandibular swelling in the absence of the typical dental causes of infection such as deep dental caries or clinically significant periodontal disease.

Case Details: An 8-year old female was referred by her oncologist for left submandibular swelling. She also had a fever of 103° and tooth pain on the left side. After hospitalization, lab results showed pancytopenia (decreased RBCs, WBCs, and platelets). CT showed a soft tissue swelling over the left body of the mandible without pus formation. The patient was in remission from acute lymphoblastic leukemia from which she was receiving maintenance chemotherapy. Extraoral exam showed left-sided pain, an erythematous left submandibular swelling, and trismus. Intraoral exam showed a well-restored primary dentition with no obvious caries. The gingival margins of the left mandibular 1st and 2nd primary molars were erythematous, swollen and tender to palpation. Tooth #K had an SSC placed about 1 year ago by her dentist, and tooth L was close to exfoliation with 3+ mobility. Tooth #K had no caries, furcation involvement, or periapical radiolucency. The patient was treated conservatively due to her depressed immune status and thrombocytopenia. She was given IV cefepime on admission and a course of IV clindamycin was added on day 2. Her swelling subsided significantly within 36 hours. She was discharged home with a course of oral clindamycin, and extraction of #K and #L were scheduled one week later in outpatient setting. On presentation to the clinic, gingiva around both teeth was healthy, tooth #K was asymptomatic, and there was no radiographic pathology present. The plan was amended to extract only tooth #L. She returned 2 weeks later with no further complaints.

Key Points:
1. Neutropenic patient with oral mucositis are at increased risk for systemic complications.
2. There is growing evidence that an inflamed or infected periodontium can act as a portal of entry for oral micro-organisms into the bloodstream.
3. A loose primary tooth which moves in response to physical manipulation can result in oral pathogens entering the bloodstream via the ulcerated gingival sulcus.
4. There is no consensus (or scientific studies) as to whether loose teeth be allowed to exfoliate naturally or be extracted in patients prior to cancer therapy.

This article highlights the need for studies that evaluate the incidence and frequency of oral complications during cancer therapy as well as what dental treatment should be performed, if any, in these patients. Also, the follow up time on this case was only 2 weeks. I would have liked a longer follow up – up to the time of exfoliation of tooth #K. 

Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation and or Radiation

Resident: Todd Bushman
Date: 10/29/2012
Pediatric Clinical guidelines
Article title: Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation and or Radiation
Author: Clinical Affairs Committee


- According to the literature the most common source of sepsis in the immunosuppressed cancer patient is the mouth.  Early and radical dental intervention, including aggressive oral hygiene measures, reduces the risk for oral and associated systemic complications.


- An oral examination should be conducted on all cancer patients before initiation of the oncology therapy.

- Existing or potential sources of infection need to be identified and treated.

- Parents and other caregivers need to be educated about the importance of optimal hygiene and oral care during and after treatment.

- Patients who receive radiation therapy to the masticatory muscles may develop trismus. Daily stretching oral exercises should start before radiation and continue throughout treatment.

- Hematological considerations:

o Absolute neutrophil count (ANC) - <1,000/mm3 defer elective dental care. Emergency dental care should be discussed with the patient’s physician and may require hospitalization.

o Platelet count – 40,000-75,000/mm3 may need to consider platelet transfusion. <40,000/mm3 defer elective dental care.

- Ideally, all dental treatment should be accomplished before cancer therapy is initiated. If dental work is needed once cancer therapy is started, treat between chemotherapy cycles - the patient’s hematological status is usually the most stable in the few days between treatment cycles.

- Dental care should be aimed at preventing infection and may need to be more aggressive for these patients. Primary teeth with pulpal involvement should be extracted, rather than treated with a pulpotomy. Permanent teeth needing endo should only be saved if the RCT can be performed in a single visit; otherwise, extract. Orthodontic appliances may need to be removed if OH is poor or if the cancer treatment protocol is putting the patient at risk for developing mucositis. There are no clear recommendations for the use of prophylactic antibiotics for extractions. If the patient will or has received radiation to the face, caution should be taken due to the risk of osteoradionecrosis.

- During cancer treatment, if moderate to severe mucositis develops, the patient may use a foam toothbrush soaked in aqueous chlorhexadine for brushing; the use of a regular toothbrush should be resumed as soon as the mucositis improves.

- Oral hygiene needs to be impeccable during cancer treatment. Xerostomia may develop; fluoride rinses and gels are highly recommended.

- Patients who have experienced chronic or severe mucositis should be watched closely for malignant transformation of their oral mucosa.

- Orthodontic care may start or resume after all treatment is complete and after at least a 2-year disease-free survival.

- If a child is planned for hematopoietic cell transplantation (HCT), all dental treatment must be completed before the transplant.

- There will be prolonged immunosuppression following the transplant; elective dentistry will need to be postponed until immunological recovery has occurred.
The objectives of a dental/oral care during cancer therapy are three-fold:
1. to maintain optimal oral health during cancer therapy;
2. to manage any oral side effects that may develop as a consequence of the cancer therapy; and
3. to reinforce the patient and parents’ education regarding the importance of optimal oral care in order to minimize oral problems/discomfort during treatment.

Hematopoietic cell transplantation
Specific oral complications can be correlated with phases of HCT.

Phase I - pre-transplantation -
The oral complications are related to the current systemic and oral health, oral manifestations of the underlying condition, and oral complications of recent medical therapy.  All dental treatment must be completed before the patient becomes immunosuppressed.

Phase II - Conditioning/neutropenic phase - Mucositis, xero-stomia, oral pain, oral bleeding, opportunistic infections, and taste dysfunction may be seen.  Dental procedures usually are not allowed in this phase due to the patient’s severe immunosuppression.

Phase III - Initial engraftment to hematopoietic reconstitution - Oral fungal infections and herpes simplex virus infection are most notable. Oral GVHD can become a concern for allogeneic graft recipients. Topical application of neutral fluoride ordesensitizing toothpastes helps reduce the symptoms.

Phase IV: Immune reconstitution/ late posttransplantationChronic toxicity associated with the conditioning regimen, including salivary dysfunction, craniofacial growth abnormalities, late viral infections, oral chronic GVHD, and oral squamous cell carcinoma.
Assesment:  The guidlines provide a wealth of information in helping us care for our patients to the best of our abilities.

Oral aspects and management of severe graft-vs-host disease in a young patient with beta-thalassemia: case report

 Kyung-Hong Cal Kim

Oral aspects and management of severe graft-vs-host disease in a young patient with beta-thalassemia: case report

Authors: de Fonseca MA, Schubert M, Lloid M

Pediatric Dentistry, 1998

Background Information:
-Commonly found in people from Mediterranean, Middle Eastern, and Southeastern Asian countries as well as in blacks.
-Reduction or impairment of the synthesis of the beta-globin chain that leads to ineffectie erythropoiesis, anemia, impaired physical growth and development, hypertrophy of the erythropoietic tissues, hepatosplenomegaly
-Heterozygous Thalassemia minor (trait), homozygous thalassemia major
-Orofacial manifestations: hypertrophy of the mandible, prominent malar eminences (chipmunk facies), retraction of the upper lip, protrusion of the anterior teeth, and malocclusion.
-Tx: multiple blood transfusion to elevate hematocrit -> iron overload -> damage to myocardium, liver, spleen, pancreas, thyroid, parathyroid, and GI mucosa
-Can be cured by bone marrow transplantation (BMT)

-One of the most significant complications of BMT
-Acute form in first 100 days post-transplant
-Chronic form between 3 and 12 months
-Viral, fungal, and bacterial infections during preparatory period and in the first month after the procedure can be life-threatening
-Preparatory conditioning for the transplant can induce mucositis, xerostomia, secondary infections, ulcerations, pain, and bleeding
-Earliest changes in the oral mucosa: patchy erythema, followed by multiple, irregular, white-grayish, striated or reticular plaques consistent with oral lichen planus.
-Dental consideration: careful physical manipulation to avoid skin breakdown, conscious sedation contraindicated (difficult airway management, difficult cardiopulmonary resuscitation)

-6-year-old Saudi Arabian male w/ beta-thalassemia major
-All his primary teeth were removed under GA a few years earlier due to multiple extensive carious lesions (poor hygiene + high-carb liquid diet)
-Compromised range of motion in manbidle (unable to protrude)
-Scarring and scleroderma-like changes in perioral region -> microstoma w/ limited opening (10mm interincisal opening)
-Atrophy or the masticatory muscles (from being unable to eat solid foods) and some degree of trismus -> further worsening microstomia
-Extensive caries on all permanent 1st molars w/ periapical radiolucencies
-Crowding, malocclusion, gingivitis, purulent exudate from molar areas.
-Broad spectrum abx
-Intensive hygiene regimen involving small one-tuft toothbrush, neutral sodium fluoride gel, normal saline rinses + diluted 0.12% chlorhexidine, daily rinses of dexamethasone for 4 weeks
-Intensive physical therapy + oral stimulation exercises -> improved mouth opening
-Extraction of compromised teeth under GA by “a team of oral surgeons” 3 months after initial visit

Assessment of the article:
Informative article describing what we should look for in patients who may have had BMT. It is unfortunate that they have to suffer through GVHD after going through chemotherapy or BMT. I hope we wouldn’t have to be the first to recognize GVHD, but case like this reminds us how important our oral exam can be in detecting more serious systemic condition.

Wednesday, October 24, 2012

Color Changes of Restorative Materials Exposed In Vitro to Cola Beverage

Resident: Matthew Freitas
Journal: Pediatric Dentistry Jul/Aug 2008
Authors: Mohan M
To evaluate the color stability of restorative materials when exposed to a cola beverage

-Three dental materials chosen:
1. RMGIC (Fuji II LC)
2. Compomer (Dyract AP)
3. Total Performance Hybrid (TPH) Composite
-3 different shades chosen per materials tested (A2,B1,C2 for composite and compomer, A2,B2,C2 for RMGIC)
-Samples were placed in a chilled, open, full can of cola and left within a humidity chamber for 72 hours.
-Scanning electron microscopy was used to characterize the surface morphology before and after polishing.

-72-hour cola exposure resulted in significant changes in color.
-Clinically all three shades of RMGIC and darker shades (C2) of composite and compomer showed significant color changes, which compromised both color stability and esthetics.
-It has been suggested that hydrophilic nature of RMGIC makes it less resistant to staining, while hydrophobic composite and compomer materials are more resistant to staining
-Polishing using abrasives introduces scratches; SEM analysis shows the surfaces of polished samples were relatively rough making them more prone to staining.
-Polished and unpolished TPH shade C2 samples displayed the most pronounced color changes of all the materials examined. It is suspected that the cola’s caramel color penetrated the material and reacted with the orange-brown pigment used to produce the C2 shade.

-Compomers and composites in the darker shades such as C2 and the RMGIC in any shade should preferably be avoided in anterior restorative applications for children for ideal esthetics.

-Some of the results suprised me, because I have always been under the impression that polishing would be more resistant to staining.
-I wonder if these same results would be observed with other drinks and foods that cause extrinsic stains.
-Also, I don't think most children are keeping cola in their mouth for 72 hours.

The Incidence of Adverse Reactions Following 4% Septocaine (Articaine) in Children

Kyung-Hong Cal Kim

The Incidence of Adverse Reactions Following 4% Septocaine (Articaine) in Children

Adewumi A, HallM, Guelmann M, Riley J

Pediatric Dentistry 2008

To report the incidence of adverse events following the use of 4% Septocaine in chidren

Background Information:
-Originated in Germany
-FDA approved in April 2000
-Contains a thiophene ring (increases lipid solubility -> faster onset) and an ester
-Equal analgesic efficacy along with lower systemic toxicity allows articaine to be used in concentrations higher than other amide local anesthetic
-2 most commonly reported local anesthetics when paresthesia occurred were articaine and prilocaine
-Complete anesthesia should last approximately 1 hour for infiltrations and up to approximately 2 hours for nerve blocks
-264 2 to 14 y/o children w/ negative hx of atopic or allergic rxn to LA
-4 short telephone interviews 3,5,24,48 hours postinjection
-Most patients received approximately 1 carpule of Septocaine (68mg)

Results and Discussions:
-More girls complained of numbness and sustained soft tissue injuries than boys
-Incidence of lip injury was higher compared to the cheek and tongue.
-Other adverse reactions (headache, confusion, and chest pain) were recorded. 5 cases of headache after 3 hours are most likely not due to use of anesthetic, and 3 reported cases of confusion coincided with 3 cases in which oral sedative was used to facilitate dental tx.
-1/3 of children experienced anxiety due to prolonged numbness
-Post-operative soft tissue injuries are likely to occur in 3 to 7 y/o children
-It is recommended that dentists should consider prescribing doses less than or equal to 5mg/kg when treating children 4 to 12-year-old.

Assessment of the Article:
It was an informative article explaining how Septocaine differs from the rest of the local anesthetic agents, but method and data gathering for the study seemed a bit unorganized and confusing. Studies comparing different age groups, children who received different amount of anesthetic, and different types of injection may be beneficial in the future to further investigate the relationship between Septocaine and its adverse reaction. 

Tuesday, October 23, 2012

Aesthetic Restorative Dentistry for the Adolescent

Resident: Mackenzie Craik

Publication: Pinkham, et al. Pediatric Dentistry: Infancy Through Adolescence. 4th Edition
Chapter 39: Aesthetic Restorative Dentistry for the Adolescent

Authors: Kaaren G. Vargas, Marcos A. Vargas, John W. Reinhardt

Fundamentals of Materials Selection
-Clinical success of composite restorations depends on adhesive systems that provide durable bonding of composite to dentin and enamel.
-Two types of composite resins can be used 1)Microfilled...filler particles average .04 microns 2)hybrid...a blend of different particle sizes is used.  
-Mechanical and physical properties of hybrid resin composites are superior to those of microfilled resins, but microfilled resins can be polished to an enamel like luster.  
-Better to use microfilled in the the esthetic zone, where occlusal forces are not as heavy.

Fundamentals of Clinical Technique
-Shade selection is always the first step, shade should be matched to a tooth that is not yet dehydrated, so match before rubber dam is placed.
-You can also polymerize a small piece of the composite on the tooth and then remove it once shade has been evaluated.
-Etch for 15 seconds and rinse for 5-10 seconds.
-Opaque and translucent materials should be used accordingly to replicate the look of dentin and enamel. 
-Carbide finishing burs, ultrafine diamonds, and finishing disks should be used for contouring and finishing.

Fundamentals of Tooth Color and Form
-In many cases, use of a hybrid composite as a foundation under a microfilled composite improves both the strength and the appearance of the restoration.
-Embrasure spaces should be symmetric whenever possible, and contours should match those of the adjacent teeth.  
-Adolescent anteriors should show little sign of wear and display prominent incisal emrasure spaces with rounded incisal point angles.

Restorations for Fractured Anterior Teeth
-If pulp is involved in tooth fracture then tooth may require pulpotomy or pulpectomy, restoring the tooth will usually require a class IV restoration.
-Composite resin class IV restorations are considered permanent restorations, they don’t always require a crown.
-Acid Etch techniques have lessened the requirements for retentive features.
-The primary retentive feature is a beveled enamel cavosurface margin of a minimum of 1.0 to 2.0 mm in length.  

Restoration of Diastemas
-Composite resin diastema closures are a viable option and can last between 5 and 10 years.
-Orthodontic treatment may be required prior to some diastema closures if gap is to wide.  
-In some patients partial diastema closure is the ultimate treatment due to the width of the diastema and considering the fact that making the teeth to wide can produce an esthetic appearance that is just as displeasing to the patient.

Restoration of Discolored Teeth
-Treatment of Hypoplastic Spots
-Can be improved with microabrasion.
-Microabrasion requires little enamel removal and does not necessitate the placement of a restoration.
-The technique for enamel microabrasion involves application of an acidic abrasive paste by a reduced-speed dental handpiece.
-Microabrasion is sometimes combined with vital bleaching.

-Lab constructed veneers
-Can be constructed from either porcelain or composite.
-Requires the removal of .3 - .5 mm of enamel but occasionally more in severely stained teeth.
-For optimum periodontal health the finish line should be kept supragingival.

-Direct Veneers
-Constructed directly in the mouth.
-Offer improved marginal adaptation.
-May be performed with or without any enamel removal.
-The composite should be applied 1-1.5 mm thick and contoured using brushes.
-Finishing and polishing is best done with burs and disks.

-Vital Bleaching
-Includes power bleaching and night guard bleaching.
-Power bleaching is an in office procedure which includes the use of high concentration hydrogen peroxide solution applied to rubber-dam isolated teeth, while heating the teeth with an electric lamp...can cause thermal sensitivity.
-Usually takes 3-4 office visits
-Night guard bleaching uses a milder peroxide solution.  It takes 2-3 weeks and is as effective as power bleaching with less thermal sensitivity.

Restoring Primary Anterior Teeth

Resident: Derek Nobrega
Title: Restoring Primary Anterior Teeth
Authors: William F. Waggoner, DDS, MS
Journal: Pediatric Dentistry. 2002. 24(5): 511-516

Main Purpose: To discuss the different options for restoring primary anterior teeth using both clinical experience and published literature.  

The author based the article on personal experience, clinical studies, and other clinical guidelines that are accepted.

Key Points:
There is insufficient controlled, clinical data to suggest that one type of restoration is superior to another, due to many factors, including behavior management, the young age of the child, parental consent, cost of treatment, reluctance on the part of the clinician and differences in caries risk of patients receiving these restorations.

Intracoronal Restorations
- Class V preps are similar to those in adult teeth, and should include small undercuts or retentive grooves incisally and gingivally to aid in retention.
They can be restored with glass ionomers, compomers, resin-reinforced glass ionomer, or composite resin.
- Class III preps are more difficult due to the small clinical crown, the relatively large size of the pulp chamber, the close proximity of the pulp horns to the interproximal surfaces and the thinness of the enamel.
In many instances, the retention of very small Class III restorations is not adequate because not enough surface area of the tooth was etched and bonded. Therefore, it has been recommended that even small Class III restorations in primary incisors have a labial or lingual dovetail or somehow incorporate a large surface area for bonding to enhance retention.

Full Coronal Restoration
- Indicated when: (1) caries is present on multiple surfaces, (2) the incisal edge is involved, (3) there is extensive cervical decalcification, (4) pulpal therapy is indicated, (5) caries may be minor, but oral hygiene is very poor (high-risk patients), or (6) the child’s behavior makes moisture control very difficult, creating difficulties in placing Class III restorations.
- Bonded strip crown = Most esthetic choice –– but most technique sensitive option - Hemorrhage or saliva on the tooth will interfere with the bond, and hemorrhage can interfere with the shade or color of the material. Additionally, adequate tooth structure must remain after caries removal to ensure sufficient surface area for bonding.
-  SSC = the easiest and most durable restoration for severely decayed primary incisors
It can be placed quickly and successfully onto very little tooth structure, even in the presence of blood and saliva, and can be easily crimped. It is, however, very unesthetic, and may be completely unacceptable and rejected by a majority of parents as a viable restorative option for their child’s teeth.
- Preveneered crowns = esthetic and can be placed successfully even with poor moisture or hemorrhage control. These crowns are not easy to fit and require a rather long learning curve, they are available in only 1 or 2 shades, so matching adjacent teeth can be difficult, and they can only be crimped on the lingual.
- Due to lack of documented support, none of these options can be definitively considered the best or superior to the rest under all clinical circumstances.

-Composite Resins - best strength, wear resistance, esthetics and color-matching capabilities of all of the materials. However, they are the most technique sensitive, require the use of acid etching and bonding agents, and are intolerant of moisture and/or hemorrhage.
- Compomers have many of the same characteristics as composite resins with similar esthetics. They may have some fluoride release and be a little more moisture tolerant than composite resins, but they are essentially handled the same way as resins.
- Resin-modified glass ionomers release fluoride, do not require etching, and are less moisture sensitive. Esthetics can be good, but not as good as compomers or composite resins. Additionally, wear and strength are not as good as the resins
- Glass Ionomers are self-curing and have a high release of fluoride. They chemically bond to tooth structure and are somewhat tolerant of moisture. Their physical properties and esthetics are not as good as the other three types of tooth colored materials. Used in Atraumatic Restorative Technique - long-term success of GIC placed into Class III preparations is not very good, ranging from 20%-73% after one year. They may provide caries control for a short time, perhaps allowing a very young child time to grow up and become more accepting of conventional treatment is the best choice.

Excellent article discussing the pros and cons of the different options for restoring primary anterior teeth. However, as the author mentioned, there is a lack of clinical support to stand up for one type of restoration over another, so selection is mostly based on the operator’s personal preference.

Bisphenol A Blood and Saliva Levels Prior To and After Dental Sealant Placement In Adults

Resident Name: Todd Bushman
Article Info: Bisphenol A Blood and Saliva Levels Prior To and After Dental Sealant Placement In Adults
by: Joyce M. Zimmerman Downs, BSDH, MS;  Deanne Shuman, BSDH, MS, PhD; Sharon C. Stull, BSDH, MS; Robert E. Ratzlaff, PhD
Reference: The Journal of Dental Hygiene Volume 84 Issue 3 Summer 2010 Main
Purpose:  This study examined the effects of a widely used (Delton® Pit &
Fissure Sealant) pit and fissure sealant material on bisphenol A (BPA) levels in blood and
saliva, among both low and high–dose groups over time.
Methods: A sample of 30 adults were randomly divided into 2 independent
variable groups: a low–dose group (1 occlusal sealant application) and
high–dose group (4 occlusal sealant applications). A test was used to examine the presence and concentration of BPA in serum and saliva after sealant placement. Differences comparing low–dose and high–dose groups were examined 1 hour prior, 1 hour post, 3 hours post and 24 hours after sealant placement.  They used a direct–competitive BPA Enzyme Linked ImmunoSorbent Assay (ELISA).
Key Points: Perinatal low–dose exposure to BPA results in functional and morphological
alterations of the rodent genital tract and mammary glands, which may predispose the tissue to
earlier onset of disease, increased infertility and mammary and prostate cancer, as demonstrated in vitro.  Fluctuations in hormonal exposure, especially estrogen during fetal development, is also thought to be a factor in prostate, breast and uterine cancers
BPA was detected in the saliva of all participants prior to sealant
placement and ranged from 0.07 to 6.00 ng/ml at baseline. Salivary BPA
concentration levels peaked over a 3 hour period following sealant placement
and returned to baseline levels within 24 hours. BPA was significantly
elevated at all post–sealant placement time periods for both the low–dose
and high–dose groups with peak levels of 3.98 ng/ml and 9.08 ng/ml, respectively.
The blood serum did not contain BPA at any point in this investigation. 
Assessment of Article:  It is interesting and important information for us to know as providers since many of our patients’ parents are concerned about the well being of their children.  Like the anti Fluoride crowd there will be parent s that question the use of our other dental products including sealants.  We need to know the facts regarding these issues.

Flowble Glass ionomer cement as a liner: improving marginal adaptation of Atraumatic Restorative treatment restorations

Resident Name: Sadler
Article Info: Flowble Glass ionomer cement as a liner: improving marginal adaptation of Atraumatic Restorative treatment restorations
Clarissa Calil Bonifacio DDS
Journal of Dentistry for Children-77:1, 2010
Main Purpose: Examine differences in adaption of using a flowable consistency GI liner with a traditional mix
Methods: 40 extracted teeth were cleaned with pumice and prepared with high speed diamond to dimensions of 3mm wide, 2mm long, and 3 mm deep.  Teeth were treated with either one application of GI or a flowable mix followed by a traditional mix.  Teeth were soaked in water for 24 hrs,  stained with methylene blue, sectioned, and examined by SEM.
Key Points:
·         GI for the study was ketac molar
·         The traditional mix was 1:1 and the flowable mix was accomplished by using half as much liquid
·         The group treated with a flowable layer at the interface was found to have a better interface and significantly less penetration of the dye then the single application
·         No voids could be seen in the flowable group while some voids were visible in the thicker mix

Assessment of Article:  I liked the articles mention of getting a better seal as it seems that a good seal is the primary factor which affects a restoration’s success.  I do think that vitrebond is pretty flowy so I think we are using the right stuff.  I do think its funny they talked about ART and then used a diamond to do the prep.