Wednesday, November 28, 2012

Effects of preterm birth on oral growth and development

Resident: Mackenzie Craik
Title: Effects of Preterm Birth On Oral Growth and Development
Author: W. Kim Seow, MDSc, DDSc, PhD, FRACDS
Journal: Australian Dental Journal 1997;42:(2):85-91
Topic: Growth and Development

Main Purpose: Examining the effects of preterm birth on oral growth and development.

Methods:  Seow studied the oral complications of preterm children attending the Growth and
Development Clinic, Mater Children’s Hospital, South Brisbane. This clinic was established in 1978 to
provide a multidisciplinary follow-up of all preterm children born at the Mater Mothers’ Hospital. To
date, these cross-sectional and longitudinal studies which cover many aspects of oral development have provided insight into the response of the oral tissues to medical problems of preterm children during the
neonatal period. The present paper reviews the results of these studies.

Key Points:
-Preterm  and  low  birthweight  children  comprise approximately 6 per cent of all live  births.
-They are prone to many serious medical problems during the neonatal period which may affect the development of oral tissues.
-Studies have shown a high prevalence of generalized enamel hypoplasia in the primary dentition of around 40-70 per cent in preterm children which is likely to be associated with low bone mineral stores. -The clinical significance of enamel defects is poor esthetics, and predisposition of the lesions to dental caries.
-Other dental defects observed in preterm children are localized enamel hypoplasia, crown dilacerations, and palatal distortions which are usually associated with traumatic laryngoscopy and prolonged endotracheal  intubation.
-Recent  studies have demonstrated that the rate of dental development, and dental eruption may be affected by preterm birth.
-Children with the lowest birthweight and shortest gestational ages have the lowest rates of dental development, particularly before six years of age.
-The results of these clinical studies may have significant implications in the dental management of preterm children.

Assessment of Article: This was more of a review of some the conditions that are observed in preterm babies.  It didn't read like a scientific study.  But a very nice broad overview.  It would be interesting to see if there have been any follow-up studies or further information gathered being that this was published in 1997.

Tuesday, November 27, 2012

Permanent Tooth Development in Children With Cleft Lip and Palate Permanent Tooth Development in Children With Cleft Lip and Palate

Resident: Matthew Freitas
Author(s): A. Borodkin et al.
Journal: Pediatric Dentistry 2008. 30:5. 408-413.
Topic: Growth & Development

-Conflicting results exist regarding differential effects of cleft lip and palate on teeth development between sexes and the proximity of teeth affected to the cleft. However, the effects of clefting on individual teeth have rarely been tested. Previous studies have found significant delays of more than 1 year in permanent tooth development, especially for males.

1. Quantify and compare permanent tooth development of cleft lip and palate patients to age- and gender-matched controls.
2. Relate these findings to cleft type and severity.
3. Examine delays in individual maxillary teeth and their proximity to the cleft.

-Retrospective chart review and radiographic analysis study.
-Panoramic radiographs of 49 cleft lip and palate patients 6- to 13-yr old were chosen randomly.
-Control patients were matched by age and gender; matched within 60 days of age.
-One examiner blindly compared the radiographs; a second examiner examined 20% to verify results.

-Cleft patients on average exhibited a delay in tooth development of 6 months.
-Boys were primarily affected while girls were not.
-Delay was independent of cleft severity; equal delay in both unilateral vs. bilateral cleft.
-Max first and second premolars and max second molars were the permanent teeth most delayed.
-Cleft patients with both primary and secondary cleft palate vs. just primary cleft showed a non-significant trend of more delay.
-No asymmetric tooth delay was observed in the results; unilateral clefts displayed symmetrical tooth development delay.

Assessment of Article:
-Overall a good study. Results and trends were similar to previous studies, but had some further detail.
-Study matched subjects to controls by age and gender, but what about race?
-Study did not mention whether subjects had undergone surgery to repair their cleft, which may have an affect on tooth development. Most surgical teams repair the palate between the ages of 6mo-1yr, which could have an affect of tooth development.

Childhood Obesity and Dental Development

Resident: Derek Nobrega
Title: Childhood Obesity and Dental Development
Authors: Kelly K. Hilgers, DDS, MS; Matthew Akridge, BA; James P. Scheetz, PhD; Denis F. Kinane, FDS, PhD
Journal: Pediatric Dentistry. 2006. 28(1) 18-22.

Main Purpose: The purpose of this study was to determine if increased body mass index (BMI) is associated with accelerated dental development in children ages 8 to 15.

Methods: The dental development ages of 104 children between the ages of 7 and 15 were determined using the Demirjian method and panoramic radiographs. The Demirjian method is based on published sex-specific tables, and evaluates dental eruption patterns on panoramic radiographs to estimate subjects’ dental ages. Subjects’ dental age differences were calculated by subtracting the chronologic age from the calculated dental age. The BMI status was determined for each subject and classified by the International Obesity Task Force (IOTF) - 63 normal weight, 23 overweight, and 18 obese subjects. The difference between chronologic age and dental age was analyzed against BMI, age, and gender using 3-way analysis of variance.

Key Points:
1. Dental development was significantly accelerated with increased BMI, even after adjusting for age and gender.
2. The mean difference between chronologic and dental age among all subjects was 0.68±1.31 years.
3. The mean dental age acceleration in normal weight children was 0.63±1.31 years.
4. The mean dental age acceleration for overweight subjects was 1.51±1.22 years.
5. The mean dental age acceleration for obese subjects was 1.53±1.28 years.

Assessment: Obesity is an increasing problem in pediatrics. This study shows that overweight and obese children have accelerated dental development which should be considered when considering treatment options and also in recognizing eruption patterns in these children.  

Chapter 25 - Space Maintenance in the Primary Dentition

Resident Name: Todd Bushman
Article Info: Chapter 25 - Space Maintenance in the Primary Dentition
John R Christensen and Henry W Fields, jr
Pinkham 5th edition 

Main Purpose: Space Maintenance considerations
Key Points:

Management of premature tooth loss in the primary dentition requires careful thought because the consequences of improper space management may influence dental development well into adolescence.

Premature tooth loss is best thought of in terms of anteriors and posteriors.  Anteriors are typically lost prematurely due to trauma and caries.  The posteriors are lost primarily to caries.

Missing primary anteriors are replaced for four reasons: space maintenance, function, speech and aesthetics.  Most research concludes that space loss is not an issue due to premature loss of anteriors.  Speech may be affected if the child has not developed speech patterns before loss of anteriors.  Feeding is not usually a problem for most children but may be for some.

Appliances for premature loss of anteriors: pedi partial removable or fixed to bands on the molars.

Premature loss of primary molars:  The molar distal to the space will drift mesial and the tooth mesially will drift distally closing the space creating loss of arch length.  Good restorative practices should be used to restore contact and tooth contours in order to preserve space.  The tooth is the best space maintenance because it exfoliates at the appropriate time and provides functionality a a space maintainer can't.  

Band and Loop: 
1. unilateral loss of the primary 1st molar before or after the eruption of the permanent 1st molar.
2.   Bilateral loss of primary molar before the eruption of the permanent incisors

the bands should be fitted and sent to the lab in the impression in the correct position, or poured up with the bands in place.  It should be cemented with zinc phosphate or glass ionomer cement.  The appliance should be monitored every 6 months.

Bilateral space maintainer:
Lower lingual holding arch: bands placed on the molars bilaterally with the lingual wire resting just above the cingulum of the permanent anteriors.
Trans palatal arch:  maxillary appliance bonded to the bands bilaterally where the wire does not rest on the palate.
Nance arch: Like the TPA but has a button that rests on the palate to aid in stability and prevent movement of the teeth.

Distal Shoe:  Used to maintain the space of a primary 2nd molar that has been lost before the eruption of the permanent 1st molar.  It is like the band and loop but extends distally with a blade that rests 1mm below the mesial marginal ridge of the 1st permanent molar.  This provides a ramp to guide the tooth into position and hold it there.  A radiograph should be taken to ensure proper placement.

Removable appliances: Used when multiple teeth are lost in a quadrant where no other space maintenance is indicated.  Compliance and retention are major factors and disadvantages to these appliances.  If worn they can restore function as well as hold the space.

Summary:  Space maintenance in the primary dentition should be considered in terms of anterior and posterior space loss.  Space maintenance is not required for missing primary incisors.  Primary incisors should be replaced only if aesthetic concerns are a factor.  posterior space maintenance is a necessity in this age group and should be performed if possible.

Pinkham Chapter 3-Anomalies of Developing Dentition

Anomalies of number
  • Reported incidence as high as 3% with double the frequency in girls
  • By far (90-98%) more common in maxilla
  • Most common is a mesiodens
  • Great variety exists in shape, size, complications
  • Incidence reported from 1.55-10%
  • Most common is third molar followed by mandibular second premolar and maxillary lateral
  • High correlation between absent primary and permanent teeth
Anomalies of Size
  • General larger or smaller teeth can be associated with hemifacial micro/macrosomia
  • Peg laterals are examples of microdontia 
  • Fusion-two teeth are fused together.  Both have two separate pulp chambers
  • Gemination-Incomplete division of single tooth bud resulting in dual crowns with single pulp chamber
  • Differentiate the two by counting teeth  
Anomalies of Shape
  • Dens Evaginatus-Extra cusp generally associated with the cingulum area maxillary central and laterals.  The cusp contains dentin and pulp and should not be equilibrated
  • Dens in Dente-Tooth within a tooth.  The invaginated portion can be very thin or openly exposed to the pulp
  • Taurodont-Large pulp chambers with stunted roots
  • Dilaceration-Very sharp bend in the roots of a tooth.  It is thought that trauma may play a role in development
Anomalies of  Structure
  • Enamel-
Amelogenesis Imperfecta-1.Hypoplastic type-Insufficient quantity of enamel is formed, both primary and permanent teeth are involved.  Teeth can be small with open contacts.  2. Hypomaturation type-Defect in enamel matrix apposition.  Enamel is of normal size but has a low radiodensity and mineral content 3. Hypoplastic/Hypomaturation Amelogenesis Imperfecta with Taurodontism-Enamel is molted and pitted with molars demonstrating taurodontism.  4. Hypocalcification type-Enamel has poorly calcified matrix which fractures easily

Environmental Enamel Hypoplasia-Can result from nutritional deficiencies as well as prenatal infections (syphillis).  Fluorosis is also an example

Localized Enamel Hypoplasia-Can result from local infecion, or trauma.

Enamel hypocalcification-defects are related to faults in the mineralization.  Caused by the same thing as hypoplasia

  • Dentin-Dentinogenesis Imperfecta-Type 1-Occurs with osteogenesis imperfecta.  Inherited defect in collagen formation.  Primary teeth seem to be more heavily affected. 
  • Type 2-Both primary and permanent equally involved with no associated OI
  • Type 3-Rare, only occured in one group of Maryland residents.  Teeth are very thin and have multiple pulp exposures
  •  Dentin Dyslplasia-Type 1-Roots tend to be short with obliterated pulps and multiple radiolucencies 
  • Type 2-Looks like DI.  They have thisle shaped pulpe chambers with lost of pulp stones
Cementum-Developmental defects involving cementum are not common.

Anomalies of color-Most notable is tetracycline staining used during permanent tooth development

Mangement of an Ectopically Erupting Permanent Mandibular Molar: A Case Report

Resident: Elliot Chiu
Title: Mangement of an Ectopically Erupting Permanent Mandibular Molar: A Case Report
Journal: Pediatric Dentistry 2008
Author: Kennedy et al
Purpose: To describe a case report of an ectopically erupting permanent mandibular molar
Case Report
-8y/o boy presents significant mesial impaction of #19
-Radiograph shows extensive root resorption on distal root of #K
-#19 and K were asymptomatic, and #K had no mobility
-LLHA type appliance with a Halterman extension was fabricated
-Appliance delivered, button bonded to occlusal of #19
-Powerchain extended from hook of Halterman to button and replaced every 2-3 weeks
-As #19 was deimpacted, the bonded button was moved more mesial to allow more force to be put on it
-Overall treatment time was 7 months
-Conventional LLHA with bands on #19 and 30 cemented once #19 was completely de-impacted

-Great results in a tough case.
-The author mentions it's important to have an ortho consult to decide if it's an extraction or non-extraction case.
-We frequently hear that mandibular molars can be distallized to a small degree, but will relapse. I wish there was a longer follow-up to see the occlusion in the permanent dentition.

Long-Term Dental Development in Children After Treatment for Malignant Disease

Resident: Jeff Higbee
Article: Long-term dental development in children after treatment for malignant disease
Journal: European Journal of Orthodontics 19 (1997) 151-159
Authors: M. Nasman, C. Forsberg, G. Dahllof

Purpose: to study, compare and quantify disturbances in dental development in long-term survivors who had received different types of treatment for malignant diseases during childhood.

- A radiographic dental examination was performed in 16 children conditioned with total body irradiation (TBI) and cyclophosphamide (CY) prior to bone marrow transplantation (BMT), and in 52 children treated with multiagent chemotherapy.

- For each child, three age- and sex-matched healthy controls were selected.

- Evaluation of disturbances in dental development and tooth size was based on planimetric measurements of mandibular teeth on panoramic radiographs.

- All teeth are affected by antineoplastic therapy started in children below 12 years.

- Because a common treatment and therapy used is multiagent often combined with radiotherapy, it is difficult to attribute defects in odontogenesis to any single agent or therapy in these cases.

- Children treated with TBI/CY exhibited more disturbances in dental development than children treated with multiagent chemotherapy.

- The most common aberration was arrested root development and short V-shaped roots (94% in patients treated with TCI/CY).

I think this was a very interesting article.  Since all teeth will be affected in some way in children treated with the agents indicated in this paper, it is important as pediatric dentists to provide follow-up care and evaluation to determine future dental treatment needs.

The Relationship Between Acute Otitis Media and the Anatomic Form of the Hard Palate

Kyung-Hong Cal Kim

The Relationship Between Acute Otitis Media and the Anatomic Form of the Hard Palate

Authors: Kim S, Donovan DM, Blanchard SB, Kowolik JE, Eckert GJ

Pediatric Dentistry Jan/Feb ’08

To determine the relationship between AOM and the shape of the hard palate

Background Information:
Acute Otitis Media
-The most common illness in children
-70% of all children have at least 1 episode of otitis media and 40% have had more than 3 episodes before the age of 6
-Inflammation of the middle ear with rapid onset and painful symptoms regardless of etiology or pathogenesis
-Exhibit systemic symptoms consistent with those of the common cold (Nasal drainage, coughing, and congestion)
-Related to abnormal Eustachian tube function
-Children with a clef palate are more likely to develop AOM
-Male > Female
-34% of recurrent AOM are associated with exposure to tobacco smoke
-Increased incidence of AOM with pacifier use
-Correlation with congenital anomalies (Down syndrome, Turner syndrome)
-“Children with deep dental overbites” at significantly increased risk for AOM

Eustachian tube
-Communication between the nasopharynx and the middle ear complex
-Ventilation of the middle ear to permit pressure equilibration
-Clearance of secretions from the middle ear to the nasopharynx
-Underdeveloped in infants and is less efficient at clearing secretions
    -18mm in length
    -Horizontal to 10-degree angle with respect to the horizontal plane
-As the child grows, clearance of secretions becomes more efficient
    -Tube doubles in length (31-38mm)
    -Repositions at a 30-to 40-degree angle
    -Moves more superiorly (10mm superior to hard palate in adults)

-Clinical examination of subject’s palatal vault with a mouth mirror and a tongue depressor
-Questionnaire completed by parent covering
    -age, race, gender
    -systemic health
    -tobacco smoke exposure
    -method of feeding during infancy
    -hx of intubation
    -hx of a finger-sucking habit and pacifier use
    -hx of AOM
    -age during initial episode of AOM
    -number of episodes of AOM
    -tx rendered for AOM

Results and Discussion:
-148 of 176 evaluated (85%) reported a positive hx of AOM, of which 76% suffered their first episode before their first birthday and 61% had more than 3 episodes of AOM
-Abx therapy (82%) was the most common method of tx, and 23% reported a hx of tube placement
-45% of subjects with high palatal vaults underwent tube placement due to multiple bouts of AOM vs. 25% of subjects with medium palatal vault
-Those exposed to tobacco smoking and those with high palatal vaults tended to have their first AOM before their first birthday
-Authors suggest that observation of a deep palatal vault may help identify children who are susceptible to early, recurrent AOM

It was an interesting article investigating the connection between the child’s dental(?) anatomy and the most common illness in children. I am curious to find out how they came up with the hypothesis that high palatal vault may be related to increased occurrence of AOM and if there is any anatomical support for this claim. It was a well-designed study, but I’d like to have seen a bigger sample size.

Wednesday, November 14, 2012

Microleakage evaluation of restorations prepared with air abrasion

Resident: Matthew Freitas
Author: Guirguis, R, et al
Journal: Pediatric Dentistry 21:6, 1999

-The objective of the study was to measure and compare microleakage around PRRs prepared conventionally or with air-abrasion, in the presence or absence of acid etching.

-100 extracted, non-carious molars were split into 4 groups of 25
-Group A: 330 bur used to open fissures, etched, Z100 posterior composite, then sealed with Concise.
-Group B: Kinetic Cavity Preparation (KCP) 1000 Whisper Jet used to open fissures, restored with same composite and sealant.
-Group C: KCP to open fissures, etched, and restored with composite, and sealant.
-Group D: KCP to open fissures, adhesive resin, and restored with composite and sealant.
-All specimens were subjected to silver nitrate staining and sectioned bucco-lingaully to assess microleakage.

-No statistical difference between groups A (no KCP) and C (KCP with Etch), or between B (KCP no etch) and D (KCP with bond).
-Group and A and C had lowest microleakage and groups B and D had the highest. (etching made a difference)
-Statistical difference found between A and B, A and D, C and B, and C and D. (groups A and C were superior).
-The study found that the use of air abrasion alone with KCP does no provide adequate sealability of PRR in the absence of etching.

-I thought this was a straight forward study. I had never heard of using air-abrasion used in this way, which is interesting but of no benefit.

The Dental Home: A primary care oral health concept

The Dental Home: A primary care oral health concept

Arthur J. Nowak

JADA Vol. 133, January 2002

Main purpose: Paper describing the concept of a dental home and its advanages

Key points:
  • Concept of a medical home was proposed in 1992
  • Observations and empirical evidence dating back 20 years supported the concept of the medical home and that it was associated with better outcomes for patients
  • At the time of publishing the concept of a dental home could only be supported by expert opinion and observation.  However, if a dental home can be similar to access to care then significant evidence exists that supports the concept.
  • Use of a dental home will increase the appropriateness and timeliness of care
  • Historically, many first visits to a dental setting were because of trauma or emergencies which often times occcured in an emergency room setting.  This was costly and often unncessary.
  • Having a dental home establishes a relationship between the patient and the dentist and also allows for preventive care and anticipatory guidance
  • Characteristics of dental home should be: Accessible, Family-Centered, Continuous, Comprehensive, Coordinated, Compassionate, Culturally Competant.
  • A knowledge of the family will help to anticipate caries risk and recommmend personalized care and preventive treatments
  • The dental home should be the place where specialized care is coordinated.
Assesement: Nice read about the dental home and why its important.  I think alot of what they said is pretty common sense but it just needed to be defined.  Things like how children are better when they are in a familiar environment and how having a dentist to consult will decrease emergency room visits but its a nice review on why we stress the conept.

Microleakage Evaluation of Restorations Prepared With Air Abrasion

Resident: Mackenzie Craik

Title: Microleakage Evaluation of Restorations Prepared With Air Abrasion

Author: Rami Guirguis, DDS, MS; Jacob Lee, DDS, FRCD(C), John Conry, BDentSc, Ms

Journal: Pediatric Dentistry 21:6, 1999

Purpose: The objective of this in vitro study was to measure and compare microleakage around preventive resin restorations prepared conventionally or with air-abrasion, in the presence or absence of Acid etch.

Methods: One hundred extracted human non carious molars were assigned to each of four groups.  Group A: fissures opened with a high speed handpiece, etched, and restored with composite and sealant.  Group B: fissures opened with KCP 1000 (air-abrasion handpiece) and restored with composite and sealant.  Group C: fissures opened with KCP1000, adhesive resin was applied, cured, and restored with composite and sealant.  No adhesive was used for groups A, B, or C.  Group D: fissures opened with KCP 1000, adhesive resin was applied, cured, and restored with composite and sealant.  All teeth were thermocycled, stained with silver nitrate, sectioned and viewed with a computer linked measuring microscope.  Measurements were recorded in relative percentages and absolute millimeters.

Results: The results of the study indicate that the greatest degree of microleakage was found in those specimens treated with air-abrasion alone or in conjunction with an adhesive resin.  Significantly less microleakage was found in specimens that were acid etched regardless of whether the mode of preparation used a conventional or air-abrasion technique.

Conclusion: The use of air-abrasion alone does not provide adequate sealability of preventive restorations.  The findings of this study do not support the manufacturer's claims which state that the use of air-abrasion reduces or eliminates the need for acid etching.

Using Anticipatory Guidance to Provide Early Dental Intervention

Resident: Derek Nobrega
Title: Using Anticipatory Guidance to Provide Early Dental Intervention (Classic 100 Article 15)
Authors: AJ Nowak and PS Casamassimo
Journal: Journal of American Dental Association. 1995. 126(8):1156-1163

Main Purpose: To discuss why preventive dental care for children must begin earlier, go beyond traditional caries management and incorporate developmental milestones and functional considerations so that each child’s individual risk for oral conditions is addressed.

Key Points:
- Previously, dental visits for children began when the child was 3 years old. At this age a child could cooperate in restorative care, was about to begin school and had all the primary teeth. Early identification and appropriate management of dental problems such as caries can minimize intervention and prevent the occurrence of negative, often costly sequelae.
- Anticipatory guidance is the process of providing practical, developmentally appropriate health information about children to their parents in anticipation of significant physical, emotional and psychological milestones.
- The current recommendations by the American Academy of Pediatric Dentistry for anticipatory guidance in pediatric dental care includes areas such as oral development, fluoride adequacy, oral hygiene and health, habits, nutrition and diet, and injury prevention
- Parents are extremely satisfied with the interaction that this approach brings, and they enjoy the functional approach to education that deals with specific events in their own family.

This article is one of the first articles advocating early intervention in pediatric dentistry. I think this approach is an excellent way to educate parents about upcoming events in their children’s lives and to prevent future problems. 

Tuesday, November 13, 2012

Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars

Kyung-Hong Cal Kim

Clinical and radiographic evaluation of partial pulpotomy in carious exposure of permanent molars

Authors: Mass E, Zilberman U

Pediatric Dentistry Jul/Aug 1993

To assess, clinically and radiographically, the long-term outcome of partial pulpotomy as a treatment modality in a large number of permanent molars with carious pulp exposure

Background Information:
-Apposition of dentin along the canal walls and pulp chamber is a continuing physiological process (RCT would stop this dentin apposition, making the tooth more prone to fracture)
-DPC is indicated mainly for mechanical small exposure in young permanent teeth with extensive vascular supply to maintain vitality of the underlying pulp until roots develop
-Partial pulpotomy (PP) is the surgical removal of only part of the pulp tissue, removing the most superficial inflamed pulp tissue and covering the wound with a CaOH dressing

-35 permanent first and second molars in 35 patients aged 7.5-25 years
-(-)Recent pain, (-)percussion, vestibular swelling, mobility, (-)internal/external resorption, (-)pathological changes in PDL, <1-2mm carious pulp exposure with hemostasis in 1-2 minutes
-RDI, pulp tissue removed to a depth of 2-3mm w/ high-speed abrasive diamond bur under rich water spray
-Saline rinse until bleeding stopped + CaOH over the wound + IRM
-Dycal over rest of the exposed dentin
-26 amalgam, 6 SSC
-Follow-up w/ cold, percussion, mobility tests

-No pathological change in 32/35 teeth + 3/35 pulpal necrosis
-No correlation found between the final restoration and tx outcome
-PP is a treatment alternative in young permanent molars with carious pulp exposure

Assessment of article:
Interesting concept similar to Cvek pulpotomy in traumatic pulp exposure. I like the fact that it offers a conservative alternative to RCT on maturing teeth. As with any other procedure in dentistry, case selection will be key in success of PP as a tx option for these teeth with carious pulp exposure. I’d be curious to find out if this partial pulpotomy procedure remains to be successful in long-term observation, preparing these teeth to receive RCT once root formation is complete.

Physical Abuse: A study of age-related variables among physically abused children

Resident: Jeff Higbee
Article: Physical Abuse: A study of age-related variables among physically abused children
Journal: Journal of Dentistry for Children July-Aug 1996
Author: Stephen A. Jessee, DDS; Monty Rieger, MS, PhD

Purpose: Dentists may come into contact with a significant number of abused children and need to be alert, therefore, to the signs and symptoms of this form of child maltreatment.  This article provides certain age-related variables among children who were suspected or known to have been physically abused.

- 266 charts from child patients were reviewed (newborn to age 17) at Texas Children’s Hospital 1994.
-  Patients were suspected of having been abused and had been reported to CPS
- Documentation from the patient’s charts was used for this study which was entered by attending physicians, nurses, and both hospital and CPS workers
- They used the definition of abuse as “physical injury that results in substantial harm to the child, or the genuine threat of substantial harm from physical injury to the child, including an injury that is at variance with the history or explanation given and excluding an accident or reasonable discipline by a parent, guardian, or managing or possessory conservator that does not expose the child to a substantial risk of harm”.
- Data were gathered into both demographic and physical findings.
- Children were assigned to one of the following age groups
Group 1: 1 yr old or less; Group 2: 2 to 5 years old; Group 3: 6 to 12 years old; Group 4: 13 to 17   years old.
- Physical findings included location of injury and type of injury.
- One investigator performed all chart reviews to standardize the data.

- Trauma to the face, head, mouth or neck was found in 2/3 of all cases.
- Many injuries were found in more than one anatomical site.
- There was no significant difference between the incidence of injury between males and females.
- The mean age for the 266 children was 3.02 years.
- A dentist was involved in an advisory capacity in only one of the cases.
- Over ¾ of children who presented with head injuries were less than or equal to 1 year old.
- 3 of 5 households of the children reported in this study were headed by single females.
- 37% of the cases, the parents of the children were married and resided in the same household.

- In cases of child abuse there is a decrease in the frequency of injury with an increase in age.
- The severity of physical abuse is greatest in infants and young children who are less able to defend themselves and whose capacity to withstand trauma is minimal.
- Age appears to be a factor with regard to both type and location of the injuries associated with physical abuse.

An analysis of 58 traumatically intruded and surgically extruded permanent teeth

Resident Name:  Todd Bushman

Article Info: An analysis of 58 traumatically intruded and surgically extruded permanent teeth 
by K. A. Ebeleseder1, G. Santler2, K. Glockner1, H. Hulla1, C. Pertl3, F. Quehenberger4.  Endodontics & Dental Traumatology 200; 16: 34-39

Main Purpose: The purpose of this study was to compare short-term with mid-term results of intruded teeth that were surgically extruded and find out the influence of different cofactors such as intrusion depth, root development stage, concomitant crown fracture and surgical manipulation on the healing results.

Methods: the Dental Clinic of the University of Graz followed 58 different teeth that had been intruded.  the following factors were noted: tooth position, age at accident, gender, root formation, cause of injury, concomitant injuries, and depth of intrusion.

Key Points:
Forty-eight teeth were repositioned surgically and splinted with wire and composite.  In nine cases with shallow intrusion depth and immature apex, spontaneous re-eruption was awaited.  In one case orthodontic extrusion was performed.  6 of the teeth were completely removed from the socket when it had to be surgically repaired. In 9 cases the teeth were exarticulated during repositioning.  The teeth were given chlorhexidine rinse for 2 weeks and antibiotics were given for 8 days.  The splinted teeth remained in the splints for 3-4 weeks.  If the crowns were fractured they were covered with CoOH and restored at 4-12 weeks.  Radiographic checks were made after 2,3, and 4 weeks.  If no signs of pulpal necrosis, further followups were made after 6 weeks and 3 months.  If there was a periodical radiolucency the pulp was removed and the root canal filled with CaOH powder and a chlorhexidine solution.  In immature teeth it was replaced until apex closure.  In fully formed teeth gutta percha and sealapex were used.

Necrotic pulps were found in 61% of all immature and 88% of all mature teeth. External root resorption (surface, inflammatory and replacement resorption) was seen in 68% of all immature and 73% of all mature teeth.  Three teeth were lost. One was lost because of epithelial downgrowth, one because of a longitudinal root fracture and one because of a new trauma.  No statistical difference was found between midterm results and short-term results except tooth discoloration.  In summary, the optimal treatment for intrusion trauma has not yet been found. In their sample, the surgical repositioning technique was preferred for practical reasons, which may have increased the incidence of ankylosis. However, only the less severe cases had been selected for non-surgical treatment.  The treatment wasn't complete until the teeth received endodontic treatment.  One of the conclusions was that these types of teeth require life long follow ups.

Assessment of Article:  It was a good article that shows very traumatically affected teeth can be followed and with the proper treatment can be saved.  The prognosis however of an intruded permanent tooth is not very good if not treated and followed closely.

Monday, November 12, 2012

Mineral trioxide aggregate vs formocresol in pulpotomized primary molars: a preliminary report

Resident: Elliot Chiu
Title: Mineral trioxide aggregate vs formocresol in pulpotomized primary molars: a preliminary report
Author: Eidelman et al
Journal: Pediatric Dentistry - 23:1, 2001
Purpose: To compare the effect of MTA to FC as a pulp dressing for pulpotomies
-45 primary molar pulpotomies were done on 26 children
-Teeth were randomly to MTA or FC group
-After coronal pulp amputation and hemostasis, pulp stumps were covered with MTA paste or FC was placed for 5min
-IRM placed, SSC restoration
-18 children returned, 32 teeth analyzed clinically and radiographically at follow-up ranging from 6-30months
Key Points
-Teeth analyzed include: 17 MTA teeth and 15 FC teeth
-None of the MTA-treated teeth showed any clinical or radiographic pathology
-1 tooth treated with FC showed internal resorption
-Pulp canal obliteration seen in 2/15 FC teeth and 7/17 MTA teeth
-Pulp canal obliteration is a sign of odontoblastic activity and is NOT considered a failure
More evidence that MTA is a great pulpal medicament. This is relatively older article, but we have reviewed numerous studies that show similar results.

Wednesday, November 7, 2012

AAPD Handbook Chapter 19: Cardiovascular Disease

Kyung-Hong Cal Kim

AAPD Handbook Chapter 19: Cardiovascular Disease

Congenital Heart Disease
-Initial left to right shunting of blood, obstruction of blood flow, cardiac defects
-Symptoms: dyspnea, cyanosis, polycythemia, clubbing of toes or fingers, syncope, coma, weakness, murmur
-Complications: Brain abscess, infective endocarditis, cerebrovascular problems, CHF, acute pulmonary edema, bleeding problems, retardation of growth
-Management: Surgery (ex: Blalock-Taussig for Tetralogy of Fallot), medication (digitalis and anti-coagulation therapy), treating complications of CHD

Rheumatic Fever
-Autoimmune reaction between normal tissue that have been altered by products of the bacteria and antibodies produced in response to alteration
-Prevalence: 5-15 y/o, temperate zones, high altitudes, substandard living condition
-Symptoms: arthritis, chorea, erythema marginatum, subcutaneous nodules
-Complications: inflammatory rxn in the hard, larger joints, skin, lungs
-Management: Pen G benzathine, codeine, salicylates

Rheumatic Heart Disease
-Cardiac damage (mostly in mitral and aortic valve) that can result from rheumatic fever
-Symptoms: murmur, exertional dyspnea, angina pectoris, epistaxis, blood in the sputum, CHF
-Complications: Scar tissue and deformity of the valve, mitral stenosis, incompetence of the aortic valve, aortic stenosis, acute pericarditis
-Management: Asymptomatic pt require no tx

Heart Murmurs
-Caused by turbulence in the circulation due to increased flow rate, change in viscosity, stenotic or narrowed valves, or a vibration of membranous structures
-Innocent murmur: turbulence in the absence of any cardiac abnormality

Cardiac Arrhythmias
-Variation in the normal rhythm of the heart beat
-Symptoms: bradycardia (<60 bpm), tachycardia (>120 bpm), irregular heart beats
-Complications: Ischemic heart disease, angina, myocardial infarction, CHF, cardiac arrest, blindness, cerebrovascular accident
-Management: Medication, pacemakers, surgery, cardioversion in emergency
-Oral complications (from medication): ulceration, lupus-like syndrome, xerostomia, petechiae

Hypertensive Heart Disease
-Symptoms: normally asymptomatic, occipital headache, visual blurriness, changes in mental status, weakness, dizziness, and angina may occur
-Complications: Renal failure, cerebrovascular accident, coronary insufficiency, myocardial infarction, CHF, blindness

Congestive Heart Failure
-Inability of the heart to deliver an adequate supply of blood to metabolic demands
-Symptoms: Fatigue, weakness, dyspnea, hyperventilation, low-grade fever, cough, insomnia, weight gain, dizziness, confusion
-Complications: Increased peripheral resistance, redistribution of blood flow to the heart and brain, increased erythropoietic activity to increase oxygen carrying capacity
-Management: medication (ACE inhibitors + diuretic), modify lifestyles,
-Oral complications: Infection, bleeding, petechiae, ecchymoses

Infective Endocarditis
-Microbial infection (bacterial of fungal) of the heart valves or endocardium
-Acute (sudden onset, S. aureus attacks normal valves), subacute (slower onset, S. viridans attacks damaged valves): subacute more common in children
-Symptoms: Weakness, weight loss, fatigue, fever, chills, night sweats, anorexia, arthralgia
-Complications: Emboli, cerebral abscesses, myocardial abscesses, mycotic aneurysms, hemorrhage, CHF
-Management: Abx therapy, abx prophylaxis

Cardiac Conditions Associated with Infective Endocarditis
-Prosthetic cardiac valves
-Previous infective endocarditis
-Cardiac transplantation recipients who develop cardiac valvulopathy

Dental Procedures Requiring Prophylaxis and Infective Endocarditis Regimens
-Any procedures that involve manipulation of the gingival tissue, periapical region of the teeth or perforation of the oral mucosa
Standard: Amoxicillin PO 1 hr prior (adult-2g, child 50mg/kg)
Unable to take oral: Ampicillin IM or IV 30 min prior (2g/50mg/kg)
Allergic to Pen/Amp: Clindamycin (600mg/20mg/kg), Cephalexin (2g/50mg/kg), Azythromycin (500mg/15mg/kg)
Allergic to Pen/Amp, unable to take oral: Clindamycin IM or IV 30 min prior (600mg/20mg/kg), Cefazolin IM or IV 30 minute prior (1g/50mg/kg)

Endocrine Disorders-Handbook Ch 20

ENDOCRINE DISORDERS: Handbook Chapter 20
Resident: Matthew Freitas

Endocrine system- glands that secret hormones into the bloodstream to regulate metabolism, growth and sexual development.

  • produces enzymes to breakdown digestible foods (exocrine)
  • secrete hormones that affect carb metabolism (endocrine)
Diabetes Mellitus
  • Characterized by hyperglycemia from defects in insulin secretion, action or both; total prevalence of 7% and 0.22% under the age of 20
  • Diagnosis: random plasma glucose >/= 200mg/dl, fasting glucose >/= 126mg/dl, 2hr plasma glucose >/= 200mg/dl during oral glucose tolerance test
  • Type I- destruction of insulin-producing beta cells, family history 3-5%, most common type of diabetes in children (1:400-600 children), classic symptom triad includes polyuria, polydipsia, and weight loss, polyphagia may be absent in children, ketoacidosis present in 15-40% of newly dx children, treated with insulin injections
  • Type II- insulin resistance, frequently overweight, family history 74-100%, treated with diet and exercise
  • Type III- secondary diabetes caused by other identifiable etiologies (genetic, syndromes, etc)
  • Type IV- gestational diabetes (2-5% of all pregnancies)
  • Long term complications: retinopathy, nephropathy, peripheral neuropathy, atherosclerotic cardiovascular, hypertension, growth impairment, infection
  • Dental/Oral findings: xerostomia, increased caries risk, candidiasis, burning mouth/tongue, taste alteration, increased risk of perio, poor wound healing, acetone breath, odontalgia
  • Dental Considerations: good med hx, morning appts, short appts, eat a usual meal with meds, minimize stress, surgical procedures may require insulin dosage adjustment, aggressive perio care, salivary substitutes, defer ortho/surgical procedures in uncontrolled patients
  • Hypoglycemic episode: stop tx, high carb beverage or IM glucagon, seek med assistance for unconscious patient 
  • secretes thyroxine (T4), triiodothyronine (T3) and calcitonin
  • Insufficient production or diminished action of thyroid hormone, 10x more common in females, 0.8% annual incidence
  • Primary- 95% of all cases, congenital (thyroid agenesis/dysplasia), acquire (Hashimoto-autoimmune), drugs transferred to fetus, iodine deficiency, radiation therapy, surgical removal, idiopathic
  • Secondary- 5% of all cases, pituitary dysfunction, hypopituitarism, pituitary necrosis (Sheehan syndrome)
  • Symptoms: fatigue, cold intolerance, decreased appetite, hair loss, dry/scaly skin, generalized edema, slow wound healing
  • Treatment: replacement T4
  • Oral Findings: enlarged tongue, delayed dental, malocclusion, gingival edema, delayed skeletal, protruding tongue
  • Dental Management: good med hx, sensitivity to stress/infxn/surgery/drugs
  • Hypermetabolic state that results from excess synthesis and release of thyroid hormones, overall incidence of 0.05-1%
  • Graves disease- overactive thyroid gland, autoimmune, most common form, 5x more women, associated with eye disease and skin lesions
  • Other Causes: excessive intake of thyroid hormone or iodine, pituitary tumor, infection, cancer
  • Treatment: antithyroid drugs, radioactive iodine, surgery
  • Oral Findings: osteoporosis, dental caries, perio, early dental/skeletal development, premature loss of primary teeth
  • produces three steroid hormones: glucocorticoids (cortisol), mineralocorticoids (aldosterone), androgens
Adrenal Insufficiency (AI)
  • Deficiency of one or more adrenal hormones
  • Primary- Addison disease, destruction of adrenal cortex
  • Secondary and Tertiary AI- problem lies at the pituitary gland and hypothalamus
  • Symptoms: fatigue, weakness, darkening of the skin, GI problems, hypotension, salt cravings
  • Adrenal Crisis: life-threatening adrenal insufficiency = shock
  • Treatment- replacement hormones
  • Oral Findings: hyperpigmented skin, delayed healing, infection
  • Dental Considerations: early warning signs of adrenal crisis, take usual steroid dose, morning appt, reduce stress, dental extractions and surgery require increased steroid dosage prior to procedure
Hyperadrenalism (Cushing syndrome)
  • Excess glucocorticoid typically from excess corticotropin (ACTH) secretion from tumors of the pituitary
  • Symptoms: moon face, buffalo hump, overweight, hypertension, purple striations of the skin 
  • Treatment: surgical resection of tumor, radiotherapy
  • Dental Findings: osteoporosis, delayed wound healing
  • Dental Management: susceptibility to fractures, implants contraindicated
  • Produces parathyroid hormone (PTH) which regulates serum calcium
  • Excess secretion of PTH
  • Primary: caused by adenomas, hypercalcemia
  • Secondary: chronic renal failure
  • Symptoms: osteoporosis, renal stones, gastric distress, Reckinghausen disease
  • Oral Findings: loss of lamina dura, decreased density of bony trabecula "ground glass", osteitis fibrosa cystical "brown tumors"
  • Reduced secretion of PTH
  • Primary: surgical removal of parathyroid gland, radiation
  • Secondary: DiGeorge syndrome, idiopathic atrophy
  • Symptoms: tetany, paresthesia of distal extremities, laryngospasm,
  • Oral Findings: enamel hypoplasia, delayed eruption, enamel attrition
  • Major role in endocrine and links to CNS
  • Hormones: thyrotropin, gonadotropins, growth hormone, corticotropin, prolactin
  • Primary: genetic defect, tumors, infection, inadequate blood flow to gland, sarcoidosis, amlyoidosis, radiation, surgical removal, autoimmune
  • Secondary: hypothalamus tumors, inflammatory disease, head injuries, surgical damage
  • Symptoms: fatigue, decreased appetite, weight loss, cold sensitivity, abdominal pain, visual disturbances, loss of body hair, short stature, infertility
  • Dental Findings of Hypopituitary Dwarfism: decreased linear facial measurements, delayed tooth eruption, smaller mandible
  • Dental Considerations: good med hx, dental caries and perio prevention

  • GH excess: acromegaly and gigantism
  • Causes: tumor, hypersecretion of GH, increased levels of IGF-I
  • Symptoms: prognathism, soft tissue hypertrophy, diplopia, barrel chest, sleep apnea, hypertension, caridovascular abnormalities, insulin resistance
  • Dental Finding: Frontal bossing, enlarged nose and lips, prognathism, malocclusion, increased spacing, macroglossia, macrodontia, temporomandibular arthritis
  • Dental Considerations: SBE consideration, management of craniofacial abnormalities, sedation consideration
***All require a thorough medical history and consult with physicians before treatment***

Tuesday, November 6, 2012

Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome

Resident: Derek Nobrega
Title: Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome
Authors: Jeffrey M. Karp DMD, MS; Gabriela G. Ganoza DDS
Journal: Pediatric Dentistry. 2006. 28(6) 547-552

Main Purpose: The purpose of this paper was to highlight the potentially malignant course of symptomatic long QT syndrome and emphasize the importance of warning sign recognition and multidisciplinary medical management of pediatric patients with this condition.

Methods: A 7 year old presented to the University of Rochester Medical Center in NY with trauma secondary to a syncopal episode. He had a medical history of long QT syndrome, an implanted cardioverter defibrillator, Pierre Robin sequence (PRS), and ADHD. He suffered avulsion of 3 permanent maxillary incisors (#7, 8, 10), that were brought in milk. Tooth #9 sustained a lateral luxation. Patient had severe Class II due to PRS-associated mandibular micrognathism. The child then developed cardiac rhythms consistent with torsades de pointes and was admiited to the cardiac ICU. The child had 3 cleft palate surgeries in the past, and was currently taking 81 mg aspirin, atenolol, and atomoxetine. On day 5 of his hospital stay, a radiograph was taken under IV sedation. The risk of dental complications
and inadequate airway management due to micrognathia and glossoptosis were found to be contraindications for extraction of the tooth under intravenous sedation. Tooth #9 was then extracted under GA 7 days later.

Key Points:
1. Awareness of the early warning signs and dental treatment considerations of LQTS patients should be used as a means of preventing cardiac events in the dental office.
2. Syncope during physical exertion commonly indicates the presence of an undiagnosed cardiac abnormality necessitating medical attention, therefore patients who present to the pediatric dentist with a personal or family history of syncope should be referred to a pediatric cardiologist for electrocardiographic evaluation prior to any dental intervention.
4. To date, there is no evidence in the dental literature to support or refute the potential that patients with Long QT syndrome can be treated safely in the dental office.
5. Dental procedural stress and emotional triggers are known to cause instability in cardiac homeostasis in the general population and arrhythmia in adult patients with ischemic heart disease, so it may be prudent to treat these patients in a hospital setting where cardiac events can be managed expeditiously by trained personnel.
6. LQTS children may require dental rehabilitation under GA as a result of:
A. their current medical status
B. the inability to manage their stress and behavior
C. the extent and invasiveness of the dental interventions needed.
7. Dental trauma as seen in this report may be more appropriately managed by extraction vs. endodontics and complex restorative care.

Assessment: Good case report outlining a relatively rare condition that may be encountered in a pediatric dental practice. Extreme care must be taken in any patients with cardiac abnormalities, and often times they are best treated under GA to prevent complications that cannot be managed in the dental office. 

Gingival Health Status of 2-15 year old Benghazi Children with Type 1 Diabetes

Resident Name: Sadler
Article Info: Gingival Health Status of 2-15 year old Benghazi Children with Type 1 Diabetes
Kumar Gujjar MDS
Journal of Dentistry for Children-78:2, 2011
Main Purpose: Compare plaque and gingival health status of diabetic children with those of healthy children
Methods: 72 Children with type-1 diabetes and 72 controls were examined and assigned gingival health and plaque scores.  The results were then analyzed
Key Points:
·         Average age of both groups was around 10 years old
·         Mild gingivitis was the average finding of the control group
·         Moderate gingivitis was the consistent finding in diabetes group
·         Statistically significant differences in the groups was found in primary, transitional, and permanent dentitions with largest difference coming in the permanent dentition

Assessment of Article:  The author notes that the current theory relating diabetes to perio disease links consistent hyperglycemia with poor collagen syntheses and generalized poor wound healing.  I think it is important to remember to be on the lookout for diabetes with children who have consistent perio problems as we may see these children more often than their physicians.