Wednesday, December 19, 2012

Ferric Sulfate Pulpotomy in Primary Molars: A Retrospective Study

Resident: Jeff Higbee
Article:Ferric Sulfate Pulpotomy in Primary Molars: A Retrospective Study
Authors:N. Smith DDS, et al
Journal:Pediatric Dentistry 22-3, 2000

Purpose: To collect clinical and radiographic data from a retrospective chart review
of patients receiving ferric sulfate pulpotomies with a sub-base of ZOE over a five-year-period.

- Data were collected from a single private practice's charts over a 5 year period.
- After exclusion criteria 242 primary molars were evaluated in 171 children.
- Follow-up times ranged from 4-57 months (means = 19 months).

- The overall radiographic success rate ranged from 74-80%.
- The frequency of normal appearing pulps decreased over time.
- The most frequently observed pulpal responses were calcific
metamorphosis (6-33%) and internal resorption (7-18%).
- Overall clinical success was 99%.
- Only 9 of the 242 teeth were extracted due to radiographic and/or
clinical failure.
- Survival analysis revealed that 3 year survival was 90%.

- The overall success rates are lower than those reported in previously
previous literature for ferric sulfate pulpotomies but are comparable
to those reported for 1:5 dilution, 5-min FC pulpotomies.

This is a good article showing that FS pulpotomies can be successful. 
Since FC is currently being criticized so much, this is a good alternative

Tuesday, December 18, 2012

Fluoride varnishes: should we be using them?

Kyung-Hong Cal Kim

Fluoride varnishes: should we be using them?

Author: Jay Vaikuntam, BDS

Pediatric Dentistry-22:6, 2000

Key Points:
-Topical fluoride agents provide effective control and protection against dental caries.
-Concerns regarding flourosis, ingestion, and toxicity have spurred recent research in reevaluating the clinical efficacy.
-When used properly, varnishes
    -Offer 40-56% reduction in caries incidence
    -36% reduction in fissure caries
    -66% reduction for non-fissured surfaces
    -51% reversal of decalcified tooth structure
    -35-21% reduction in enamel demineralization
    -Has a cariostatic effect on approximal caries
-Once obvious cavitation has occurred, it is more appropriate to place a restoration.
-Useful alternative for caries control in special needs patients (developmental disabilities, children receiving head and neck radiation, children on chronic oral meds)

Types of fluoride varnish
-5% NaF formulation (1ml varnish = 50mg NaF = 22.6mg F)
-FDA restricts use as a desensitizing agent for hypersensitive teeth

Fluor Protector
-Each vial contains 0.4ml (1ml varnish = 1mg F)
-Lower pH than Duraphat, less viscous than Duraphat

-5% NaF formulation (1ml varnish = 22.6mg F)
-Artificially sweetened with xylitol = improves taste and patient acceptability

-5% NaF varnish in a resinous base (1ml varnish = 50mg NaF)
-Unit-dosed fluoride varnish (0.25ml or 0.40ml based on the number of teeth)
-Avoids waste, and prevents over-application and over-ingestion

-Frequency is best determined based on individual caries risk
-Most often used regimen is semi-annual applications
-Plaque removal is not critical prior to varnish application
-Most manufacturers recommend a professional prophy prior to varnish, although it can be replaced with a toothbrush prophy
-Meticulous drying of teeth prior to application is not critical as most varnishes set in the presence of moisture
-Usually 0.5ml-1.0ml is more than adequate for the entire dentition
-Avoid brushing for the rest of the day, avoid eating for the next two hours
Ingestion and toxicity
-Potential toxic dose for fluoride is 5mg/kg (0.5ml fluoride = 11.30mg ingested)

Primary molar pulp therapy – histological evaluation of failure

Resident: Derek Nobrega
Title: Primary molar pulp therapy – histological evaluation of failure
Authors: Waterhouse PJ, Nunn JH, Whitworth JM, Soames JV
Journal: International Journal of Paediatric Dentistry 2000. 10:313-321.

Main Purpose: To compare the clinical, radiographic, and histological outcome of cariously exposed primary molars that were extracted due to unsuccessful pulp treatment from either formocresol or calcium hydroxide.

Methods: 26 boys and 26 girls were involved in the study. Primary molar teeth requiring pulp therapy were randomly assigned to either to formocresol group or the calcium hydroxide group. In this group, 79 teeth required pulp therapy – 44 in the formocresol group, and 35 in the calcium hydroxide group. Of the teeth treated, 2 (5%) of the formocresol teeth were extracted, and 4 teeth (11%) of the calcium hydroxide teeth failed. Of the six teeth extracted, 5 were used in histological studies.

Key Points:
1. Extracted teeth (failures) treated with Calcium hydroxide teeth showed reactionary dentin bridge formation.
2. Extracted teeth treated with both calcium hydroxide and formocresol had narrowing of root canals, indicative of appositional reactionary dentin deposition.
3. Pus cells were evident in all extracted teeth.
4. Histologically, there was resorption of reactionary dentin within the root canal.
5. The average time between treatment and failure was 11 months.
6. Radiographic evidence of reactionary dentin should not be an indicator of successful outcome of pulp therapy, but rather a reaction by the traumatized pulp tissue that may serve to act as a partial barrier.

The teeth treated were all restored differently, but not separated in the study. The authors used amalgam, glass-ionomer cement, composite, and SSCs. It would be interesting to see how the failures were restored, and if the restoration used was linked to failure. Also, the study looked at only 6 failures, of which only 5 were able to be studied histologically. 

Efficacy of preformed metal crowns vs amalgam restorations

Resident Name: Todd Bushman
Article Info: Randall R C, Vrijhoef M M, Wilson N H. Efficacy of preformed metal crowns vs. amalgam restorations: in primary molars: a systematic review Journal of the American Dental Association 2000; 131(3): 337-343

Main Purpose: To evaluate the efficacy of preformed metal crowns vs amalgam restorations in primary molars by means of a literature review and meta-analysis

Methods: A total of ten studies were included (4410 patients) comprising eight retrospective studies, one non randomized clinical trial (188 patients) and one prospective evaluation (732 patients).
Included studies were published between 1975 and 1997 and involved patients from different countries and of different ages at restoration placement.
Key Points: 
The following information was not consistently or comprehensively reported: characteristics of patients; and decision process by which an amalgam or PMC restoration was selected. Other problems included the difficulty in establishing the correct cause of failure. Four studies included failures due to pulp inflammation that were seemingly not directly associated with the restoration. In three studies all failures due to pulp inflammation were counted as failures of the restorations.
Reason for failure: The main reason given for true restoration failure for PMC was loss of a crown leading to the need for recementation, and secondary caries and fracture for amalgam
Every study demonstrated SSCs to be a better restoration for multi-surface lesions.  Most of the studies used SSCs for larger lesions, which may allow interpretation that they were even more successful than indicated.
The authors surmised that the Braff study, which showed the least success for SSCs, used a non-anatomical preformed crown that required extensive trimming and adjustment, which could be the cause of some failures. 

4 studies excluded failures of pulpal inflammation if they didn’t think the inflammation was related to the restoration. In the other studies, pulpal inflammation was considered a failure. 
The authors recommended that studies done looking at newer cements for SSCs

It was clear that there were differing methodologies and variability in the data among the studies but all results still sided with the SSC group.

Assessment of Article:  Although the studies had their limitations it was very conclusive.  I think it was pretty definitive that ssc's are superior to amalgam as a method for restoring class II restorations and large carious primary teeth

Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury.

Resident: Mackenzie Craik
Article: Long-term prognosis of crown-fractured permanent incisors.  The effect of stage of root development and associated luxation injury.
Journal: International Journal of Paediatric Dentistry 10: 191-199
Authors: Robertson, Andreasen, Andreasen, Noren.

Objectives: The aim of the present study was to investigate pulp healing responses following crown fracture with and without pulp exposure as well as with and without associated luxation injury and in relation to stage of root development.

Methods: The long-term prognosis was examined for 455 permanent teeth with crown fractures, 352 (246 with associated luxation injury) without pulpal involvement and 103 (69 with associated luxation injury) with pulp exposures.  Initial treatment for all patients was provided by on-call oral surgeons during the emergency appointment.  In fractures without pulpal involvement, dentin was covered by a hard-setting calcium hydroxide cement (Dycal), marginal enamel acid-etched (phosphoric acid gel), then covered with a temporary crown and bridge material.  In the case of pulp exposure, pulp capping or partial pulpotomy was performed.  Therafter treatment was identical to the first group.  Patients were then referred to their own dentist for resin composite restoration.

Results: Patients were monitored for normal pulp healing or healing complications for up to 17 years after injury.  Pulp healing was registered and classified into pulp survival with no radiographic change, pulp canal obliteration, and pulp necrosis.  Healing was related to the following clinical factors: stage of root development at the time of injury, associated damage to the periodontium at time of injury (luxation) and time interval from injury until initial treatment.  crown fractures with or without pulp exposure and no concomitant luxation injury showed pulp survival in 99%, pulp canal obliteration in 1%, and pulp necrosis in 0%.  Crown fractures with concomitant luxation showed pulp survival in 70%, pulp canal obliteration in 5%, and pulp necrosis in 25%.  An associated damage to the periodontal ligament significantly increased the likelihood of pulp necrosis from 0% to 28% in teeth with only enamel and dentin exposure and from 0% to 14% in teeth with pulp exposure.

Conclusions: In the case of concomitant luxation injuries, the stage of root development played an important role in the risk of pulp necrosis after crown fracture.  However, the primary factor related to pulp healing events after crown fracture appears to be compromised pulp circulation due to concomitant luxation injuries.

Monday, December 17, 2012

Communication in Orthodontic Treatment Planning: Bioethical and informed consent issues

James L. Ackerman DDS; William R. Proffit DDS

The Angle Orthodontist Vol 65 No.4 1995

Main Purpose: Opinion paper about treatment recommendations and ethical considerations associated with orthodontic treatment

  • Historically treatment recommendation came from a parental perspective where the practitioner recommended treatment with little input form the patient however a shift is now taking place where patients are involved as co-decision makers
  • Patients should be presented with all treatment options along with their risks and benefits
  • Patients and dentists may have a very different idea of what a "good outcome" is.  The patient may want an acceptable outcome with the least treatment time
  • Dentists also may be hesitant to suggest a very aggressive treatment plan out of fear that the patient may reject treatment completely.  
  • Software and photo simulations are effective in helping patients decide on what treatment option they will choose.
  • Research has shown that while patients shown a photo prediction have higher expectations of treatment but also have the same level of satisfaction. 
  • Treatment conference should consist of 3 phases-1) Present findings and a prioritized problem list.  2) Risk/Benefit analysis and treatment alternatives 3) Discussion of expectations and deciding on a plan 
Assessment: It was a pretty easy read.  Had a couple of cases they talked about that showed two polar opposite treatments where the patients had good results with complete opposite approaches.  The take home message is that its important to let patients and parents be involved in the decision making.  

The Biological Mechanisms of Early Childhood Caries

Resident: Matthew Freitas
Author: W. Kim Seow
Journal: Community Dent Oral Epidemiol 1998; 26: Supplement 1:8-21

-The aims of the paper are to review the biological mechanisms involved in ECC and to screen factors which might provide clues to its complex etiology.

-The salivary pellicle begins to adhere immediately after even thorough cleaning and acts as lubrication, acid buffer, prevention of crystal growth and helps remineralization. It also has many other protective factors such as antimicrobial systems and bicarbonate buffering capacity. Saliva also includes immunological factors such as IgA, sIgA, IgG and phagocytes. Once the pellicle is formed, Streptococcus species can begin adhering. As the biofilm develops the bacterial population sways toward Actinomyces. The biofilm produces both acid and alkaline products, the balance of which is essential in determining its cariogenicity. The mutans streptococci family has a number of traits which lends itself to the carious process; they create water insoluble adhesion glucans, production of intracellular polysaccharide which allow acidogenic activity during periods of limited exogenous carbohydrate consumption, high aciduric capabilities. Mutans species are not typically found in predentate children, since they typically need a non shedding surface to colonize. The infection rate increases as more teeth erupt into the mouth and the earlier colonization begins, the higher the likelihood of ECC. Dental malformation is another contributing factor to ECC, since it often creates an environment with deep noncleansible fissures, as well as enamel which is less resistant to acidogenic decay. Also, teeth, even those which are congenitally sound, are most susceptible to decay immediately upon eruption before they can undergo any post-eruptive maturation. Sucrose, which is the most common dietary sugar and the most closely linked to dental decay, is unique in that one of its byproducts is plaque dextrans which are essential in the adherence and thus the progression of dental decay. The review reports that bovine milk is not cariogenic since exposure to lactose did not sufficiently lower the pH to cause demineralization. The review does warn of human milk and on demand breast-feeding, milk formulas and acidic fruit drinks. Fluoride is noted to have a multivariable positive effect in reducing cariogenic activity.

Key points/Summary : Dental caries is a complicated, multivariable disease which affects millions of children worldwide. The interpretation of universal and individual factors are essential in the prevention and elimination of this disease.

Bacteremia of dental origin and antimicrobial sensitivity following oral surgical procedures in children

Resident: Elliot Chiu
Title: Bacteremia of dental origin and antimicrobial sensitivity following oral surgical procedures in children
Journal: Pediatric Dentistry 1998
Author: Roberts et al
Purpose: To estimate the prevalence, intensity, and nature of bacteremia in children following OS procedures and determine the effectiveness of antibiotics.
-207 children treated under GA were divided into 4 groups: (I) control group, II (single tooth extraction), III (multiple tooth extraction), IV (gingival flap)
 -Blood samples were taken in each group, grown in broth culture, and analyzed
-Dental plaque deposits, gingivitis, spontaneous gingival bleeding, and the presence/abscence of dental abscess were assessed
-Positive broth cultures: Group 1 - 11%, Group 2 - 43%, Group 3 - 54%, Group IV - 43%
-Isolated organisms ranged from 1-3400 colony forming units per milliliter
-Erythromycin, gentamycin, penicillin G, and teicoplanin were 80% effective against isolates, while chlorhexidine, amoxicillin, clindamycin, and vancomycin were 92-100% effective
-This article was done in 1998. Newer studies have been out and newer guidelines have been established. It's interesting to see how much everything has changed!

Wednesday, December 12, 2012

Knowledge and Attitudes of Arizona High-School Coaches Regarding Oral-Facial Injuries and Mouthguard Use Among Athletes:

Resident: Matthew Freitas
Author(s): R. Berg et al.
Journal: JADA 1998. 129. 1425-1432.

-Adolescents who participate in collision sports are at high risk of experiencing an oral-facial injury. Mouthguard use is required in football, ice hockey, and rugby, and only recommended in other sports such as wrestling, basketball, baseball, softball, soccer or volleyball. Although mouthguard use is required and recommended in these collision sports, the reality is that most adolescents are not wearing them and there’s a lack of advocacy of mouthguards by coaches.

Common Complaints by Athletes:
-The three most common complaints regarding mouthguards:
1. discomfort
2. difficulty breathing
3. difficulty speaking

-Assess the perceptions and attitudes of high-school coaches regarding mouthguard use in sports in which mouthguard use is optional.

-11 item questionnaire given to 1,160 coaches of nine sports- wresting, boys’ and girls’ basketball, baseball, softball, boys’ and girls’ soccer and boy’s and girls’ volleyball in Arizona High Schools.

-508 of 1,160 completed- 43.7%

Frequency of oral-facial injuries:
Sport                                At-least 1 injury per season         Loose/Broken Teeth         Soft tissue injury
Wresting (59)                       88.1% (55)                                  25% (13)                          86.5% (45)
B Basketball (82)                 85.4% (70)                                  27.1% (19)                       88.6% (62)
G Basketball (88)                 78.4% (69)                                 18.8% (13)                        91.3% (63)
Baseball (78)                        75.6% (59)                                 27.1% (16)                        78% (46)
Total (508)                            71.5% (363)                               21.5% (78)                        82.4% (299)

Mouthguard Use and At-least 1 injury in a season:
Injury/No Mouthguard- 48%
Injury/Mouthguard- 24%
No Injury/Mouthguard-24%
No Injury/No Mouthguard- 4%

When coaches were asked, “Would you encourage your athletes to use mouthguards if they were provided free of charge?” 31.3% said they would not!

-High risk sports for oral-facial injury were identified: wrestling, basketball, baseball and softball.
-73% of the coaches indicated that they were aware that their athletes were at risk of such injury.
-Despite risk, coaches reported use of mouthguards is far from common.
-Most coaches did not provide educational programs or materials supporting mouthguard use.
-The authors points out the need for major educational efforts by dental professionals supporting mouthguard use for athletes. The education should be geared towards coaches, athletes, school nurses, and parents.

-It would have been interesting if they assessed the type of mouthguard used: professionally fitted or OTC.

EVA mouthguards: How thick should they be?

Resident Name:  Todd Bushman
Article Info:
EVA mouthguards: How thick should they be?
B. Westerman1, P.M. Stringfellow2 & J.A. Eccleston3
1General practitioner, 2Professional engineer, 3Department of Mathematics, The University of Queensland

Main Purpose: To determine the optimal thickness of a mouthguard.  A major consideration in the performance of mouthguards is their ability to absorb energy and reduce transmitted forces when impacted.  The thickness of mouthguard materials is directly related to energy absorption and inversely related to transmitted forces when impacted. However, wearer comfort is also an important factor in their use.
While thickness of material over incisal edges and cusps of teeth is critical, just how thick should a mouthguard be and especially in these two areas?

Transmitted forces through different thicknesses of the most commonly used mouthguard material, ethylene vinyl acetate (EVA),
were compared when impacted with identical forces which were capable of damaging the oro-facial complex.  The constant impact force used in the tests was produced by a pendulum and had an energy of 4.4 joules and a velocity of 3 meters per second. 

• Transmitted forces measured through samples of EVA
• EVA had Shore A Hardness of 80
• Constant impacts produced by impact pendulum
• Test impacts all had energy of 4.4 joules and 3 meters per second velocity
• Flat circular impact head 12.5 mm in diameter
• 20 test impacts on each sample (different site each time)
• Force sensor measured transmitted forces
• Minitab and Microsoft Excel used for statistical analysis

Key Points:   

measurements in kN
1mm – not recorded
2mm – 15.7
3mm – 11.4
4mm – 4.38
5mm – 4.03
6mm – 3.91

The results show that impact forces on the teeth decrease with each mm of material.  However, that increase drops off dramatically after 4mm.  When EVA mouthguard material with a Shore A Hardness of 80 is used in the manufacture of mouthguards, optimal energy absorption and reductions in transmitted force occur when the material is approximately 4mm thick. Further increases in thickness do not result in major improvements in performance.

Thicker mouthguards are often met with wearer resistance because of discomfort from lip and cheek displacement, speech interference and also respiratory restrictions.  So there is a balance that must be met between optimal protection and optimal usability.

Assessment of Article:  This information is good to know since we deal with adolescents who
will be participating in sports and would benefit from mouthguard use..

Pinkham Chapter 40: Sports Dentistry and Mouth Protection

Resident: Jeff Higbee
Textbook: Pediatric Dentistry – Chapter 40 Sports Dentistry and Mouth Protection
Author: Pinkham, et al

 Medical Assessment

- It is advisable as part of a thorough medical history to ask parents about their children’s athletic activities.
- A complete physical by their physician is important because several medical conditions in children may limit or disqualify them from participating in athletics.
- Play ability must be determined on a case-by-case basis.

 Intraoral Assessment

- Should include, examination for accurate dx and proper management of dental caries, juvenile periodontal disease, hard and soft tissue pathology, congenital anomalies, and developmental occlusion.
- Alveolar bone surrounding primary teeth is less dense than the alveolar bone surrounding permanent teeth making traumatic dislocation injuries more common.
- Young athletes should be examined both radiographically and clinically.
- Class II div I patients are more prone to dental sports related injuries.
- 3rd molars should be evaluated in young athletes.
- Since tobacco use is common among student athletes, the soft tissue should be evaluated frequently to evaluate any soft tissue changes.

 Dietary Assessment
- A thorough dietary assessment should be done with student athletes.
- Amateur boxers and wrestlers practice aberrant eating behaviors and intentionally become dehydrated to meet weight classification requirements.   These practices can have an effect on
strength and performance and also cause problems with the cardiovascular system.
- Hypoglycemia may occur, signs include: palpations, sweating, confusion, irritability, headache, seizure, and unconsciousness. 
- Athletes may starve themselves to make weight or eat excessively to gain weight for sports such as football.  Both situations should be evaluated.

 Mouth Protection

- Intraoral mouth guard is the single most important device to protect from dental injury and jaw fractures.
- There are only a few sports that require mouth guards, boxing, football, ice hockey, lacrosse, and women’s field hockey.
- It is our responsibility as oral health care providers to advocate to promote the enactment of rules requiring the use of mouth guards in other contacts spots not listed above.

 Types of Mouth Guards

- Type I: Stock (not recommended)
- Type II: Mouth formed
- Type III: Custom fabricated (over a cast model)

 The mouth guard should:
- Be fitted by a dentist
- Cover all maxillary teeth in the arch except in patients with mandibular prognathism, in such cases all the madibular teeth should be covered instead.
- Patients with ortho or congenital anomalies such as CP should be provided mouth guards only under the supervision of a dentist.

 The criteria for properly fabricated and fitting mouth guards as stated by the International Academy for Sports Dentistry are:
- Adequate thickness to reduce impact
- Retention so guard doesn’t dislodge on impact
- Speech considerations equal to the demands of the sport
- A material that meets FDA approval
- Wearing length equal to one season of play

Tuesday, December 11, 2012

Scale of protection and the various types of sports mouthguard

Resident: Derek Nobrega
Title: Scale of protection and the various types of sports mouthguard
Authors: D G Patrick, R van Noort, M S Found
Journal: Br J Sports Med 2005; 39: 278–281.

Main Purpose: To present a grading system of the protection offered by various types of mouthguard, together with an indication of associated risks, in order to make athletes aware of the consequences of improper or no mouth protection.

Methods: A review of the literature on mouthguards, mouthguard materials, and novel laminates for mouthguards.

Classification of Mouthguards:
Stock mouthguards
Stock mouthguards come in different sizes, are ready to use, and are mostly made from either PVC, polyurethane, or a co-polymer of vinyl acetate or ethylene. Generally, stock mouthguards are thought to be the least favorable as they offer the minimum protection.
Mouth formed mouthguards
Mouth formed mouthguards are known as ‘‘boil and bite’’ mouthguards, where a thermoplastic rim is heated in hot water then placed in the mouth and molded by biting and sucking. These mouthguards have a poor fit on the teeth and tend to be thin over prominent teeth that are prone to damage.
Custom made mouthguards
Custom-made mouthguards are made in a dental laboratory on a cast taken from an impression supplied by a dentist. A thermoplastic material is heated in a pressure or vacuum-forming machine and when soft enough is placed over the cast and air pressure or a vacuum is applied which closely adapts the soft material to the cast. Of the types listed it is generally thought that the custom made mouthguards are the best and offer the most protection.

Grading System:
Grade                         Feature
10                       Ultimate aim: grades 8 and 9 combined
9                         Passed effective instrumented test to evaluate mouthguards
8                         Custom made mouthguard using improved design and materials
7                         Custom made mouthguard using improved materials
6                         Brand new custom made mouthguard
5                         Custom made mouthguard of insufficient thickness
4                         Old custom made mouthguard, 2–5 years old
3                         Old custom made mouthguard, >5 years old
2                         Boil and bite mouthguard
1                         Stock mouthguard
0                         No mouthguard

Assessment: Review article that really only described the different types of mouthguards and provided a proposed grading scale that would allow athletes to choose a mouthguard on the level of protection required. The authors did make an interesting point that young athletes are willing to pay for expensive uniforms, shoes, and equipment, but little thought is ever given to protecting the teeth. 

Attitudes concerning mouthguard use in 7- to 8-year-old children

Kyung-Hong Cal Kim

Attitudes concerning mouthguard use in 7- to 8-year-old children

Authors: Walker J, Jakobsen J, Brown S

Journal of Dentistry for Children May-Aug 2002

To determine the acceptability of 3 types of mouthguards and to determine parents’ attitudes toward their use.

Background Information:
-First known mouthguard in 1892 by Dr. Woolf Krause, an English dentist, for his son
-Advantages of mouthguards: protection of the teeth, prevention of jaw fractures, reduction of head and neck injuries, improvement of athletic confidence, and economic considerations of tx costs resulting from dental trauma and jaw or head injuries
-Disadvantages: Discomfort, difficulty in breathing and speaking, reaction of fost tissues due to a poorly fitting appliance, no incentives from the sports groups to promote or make rules regarding the use of mouthguards

-3 soccer team of 7 and 8-year-old boys and girls in Iowa City, Iowa
-Random assignment to 3 groups of mouthguards
-Stock, mouth formed (boil and bite), and custom-made
-2 Questionnaires given to parents to fill out 2 weeks after using the mouthguard and after the season.

-Stock group: Use of mouthguards decreased over the course of the season from 70/67% (practice/competition) to 43%/64%
-Custom group: Use of mouthguards decreased over the course of the season from 81/92% (practice/competition) to 75/83%
-Mouth-form group: Use of mouthguards slightly increased over the course of the season from 55/66% (practice/competition) to 62/68%
-Children using custom-made mouthguards were more enthusiastic about their use
-Inverse relationship exists between the ease of fabrication, and comfort and function; the easier to fabricate, the less desirable to wear
-Wearing an ill fitting mouthguard may facilitate development of an attitude in the user that the mouthguards are uncomfortable and can interfere with the playing of the game.
-Parents indicated that their children should wear mouthguards where an injury may occur and the majority of parents indicated that they would use a service that would provide a mouthguard
-Only 13 of 56 parents were willing to pay $25.00 minimum fee to obtain custom mouth protection.  

Assessment of the Article:
Good study, although results seemed predictable. What was surprising was the increased use of mouth form mouthguards (although worn, chewed up mouthguards, in my opinion, fit better for some odd reason) over the course of the season. It is unfortunate that virtually all parents said they would like to give their children custom-made mouthguards but only less than 25% of them were willing to pay $25.00.

Parental perceptions regarding mandatory mouthguard use in competitive soccer

Parental perceptions regarding mandatory mouthguard use in competitive soccer
JM Pribble, R F Maio, GL Freed

Injury prevention 2004

Objective: To understand factors influencing parental perception of the importance of a mandatory mouthguard in competitive youth soccer

Methods:  Web based survey was e-mailed to  parents of children aged 8-14 who participated in fall soccer in 2002 was conducted.  The survey contained 34 questions with statements regarding mouthguard use.  There were specific questions regarding history of injuries, mouthguard use and educational material.

·         120 surveys were returned
·         Average age was 11.8 years old
·         14% reported wearing a mouthguard
·         11% reported having suffered an injury
·         92% thought mouthguards would prevent an injury
·         Only half thought mouthguards should be mandatory
·         30% reported that their dentist/doctor recommended a mouthguard
·         Recommendation by a medical professional was associated with mouthguard wear
·         Parental reported barriers to mouthguard use were: discomfort 42%, peer pressure 19%, difficulty breathing 17%, and the fact that mouthguard use was not mandatory.
Assesment:  Nice article about parental perception.  I think that counseling parents about mouthguards is important although I do think that convincing them to wear them during endurance “non-contact” sports may be challenging.  I would like to see recommendations for full-coverage motocross style helmets for bikes and skateboards as I think we see a lot of injuries from those activities which are pretty devastating.

Custom Sports Mouthguard Modified for Orthodontic Patients and Children in the Transitional Dentition

Resident Name: Elliot Chiu
Title: Custom Sports Mouthguard Modified for Orthodontic Patients and Children in the Transitional Dentition
Author: Theodore P. Croll, DDS
Journal: Pediatric Dentistry 2004
Purpose: To document the fabrication of a custom mouthguard for a 10y/o boy and 9y/o girl undergoing orthodontics.
Background Info
Due to the change in position and eruption/exfolitation of teeth during orthodontic treatment, a custom mouthguard may not fit soon after the initial impression.
Rope wax is placed over brackets prior to an alginate impression. On the model, Mortite brand window sealing compound is placed over orthodontic fixtures and in regions of prospective tooth movement. Proform brand mouthguard material (5mm) is vacuum formed.
Key Points
-Author states 5mm thickness makes for a sturdier and more protective mouthguard without opening the bite significantly.
-By incorporating this space inside the mouthguard to accomodate for tooth movement, a custom mouthguard can last much longer.
This technique is a logical way to make a custom mouthguard for our ortho athletes. Since you are blocking out so much tooth structure on the cast, I’d be curious to see if retention is an issue.

Monday, December 10, 2012

Parental Attitudes Toward Mouthguards

Resident: Mackenzie Craik
Article: Parental Attitudes Toward Mouthguards
Author: Nadia Diab,  DMD Arthur  P.  Mourino, DDS, MSD
Journal: Pediatric Dentistry--19:8, 1997.

Methods: An 11-item,  one-page questionnaire was mailed to 1800 parents chosen at random in the  Henrico County, VA public school system.  Parents were asked questions such as "who should be  responsible  for  mouthguard wear?, what sports should require mouthguards?, and has [their] child ever sustained an oral or facial injury?"

Results: The parental responses indicate that mouthguard enforcement is the responsibility of both parents and coaches. Of the total injuries reported, 19% were sustained in  basketball, 17% in baseball,  and 11% in soccer.  Despite these high injury rates,  however, there was a lack of perceived need for  mouthguard use in  these sports.  When asked which sports should require a mouthguard rule, the sports that generated the most responses were, in  decreasing order, football,  boxing, ice hockey, wrestling, field hockey, and karate.  Parents were more likely to require mouthguards for their sons than daughters, and more likely to require them for their children who participated in a mandatory mouthguard sport, a contact sport, or who had been previously injured.

Conclusions: The authors conclude that because parents view themselves as equally responsible as coaches for maintaining mouthguard use, both groups should be  targeted and approached as a possible source for the recommendation of mandatory mouthguard rules in basketball, baseball, and soccer.

Assessment: I found it interesting that parents are more likely to require their sons to where mouthguards than they are for their daughters, and also the fact that they don't feel that mouthguards are as important for such sports as basketball, baseball, and soccer when in all actuality this is where the highest percentage of total sports related injuries come from.

Wednesday, December 5, 2012

The Investigation of Major Salivary Gland Agenesis: A Case Report

Resident: Mackenzie Craik
Article: The Investigation of Major Salivary Gland Agenesis: A Case Report.
Journal: Pediatric Dentistry 23:2, 2001.
Author: Hodgsen, Shah, Porter

Main Purpose/Focus: Salivary gland agenesis is an extremely uncommon congenital anomaly, which may cause profound xerostomia in children. The oral sequelae includes dental caries, candidosis, and ascending sialadenitits.  The present report details a child with rampant dental caries secondary to xerostomia. Despite having oral disease for many years, the congenital absence of all the salivary glands failed to be established until early adulthood.  The appropriate investigation and management of the xerostomic child allows a definitive diagnosis to be made and attention focused on the prevention and treatment of resultant oral disease.  Salivary gland aplasia may occur in isolation or may be associated with other ectodermal defects, particularly lacrimal apparatus abnormalities.

Case: In 1988, a 4 1/2-year-old Caucasian female was referred to the Department of Pediatric Dentistry of the Eastman Dental Institute for Oral Health Care Sciences for the extraction of several grossly carious deciduous teeth under general anesthesia. A review of her past medical history revealed a congenital obstruction of the right nasolacrimal duct, which had been surgically corrected at the age of 10 months. She was below the 50th percentile for height and weight. The reason for this failure to thrive failed to be established. There was no family history of ectodermal defects. At the initial consultation her lips were dry, however there was no specific detail recording a subjective xerostomia. Her rampant caries was attributed to poor oral hygiene and a highly cariogenic diet. All the primary teeth were extracted under general anesthesia.  This pattern continued with many of her adult teeth as well, as she was being treated initially with diet counseling and hygiene instructions.  The definitive diagnosis of agenesis of all the major salivary glands, with resultant oral candidosis and rampant dental caries. The patient’s symptoms of xerostomia significantly improved following the introduction of a salivary substitute with fluoride. Definitive restorative treatment was undertaken when an excellent standard of oral hygiene, a non-cariogenic diet, the regular use of a daily fluoride mouthwash, and, as required, saliva substitute resulted in the arrest of carious process.

Summary: Saliva is integral to the health of the oral tissues.  A significant decrease in the caries rate in this case only occurred once the definitive diagnosis was presented to the family and a fluoride containing artificial saliva was introduced.  In children with the congenital absence of only one or two
major salivary glands, flow may be stimulated with sugar-free chewing gum. However, the management of children with an absence of all glands remains unsatisfactory. Saliva substitutes
require frequent administration and fail to mimic the physiological variation in salivary flow. Compliance is therefore often problematical. As in all patients with xerostomia regular clinical review is essential for this patient’s long-term oral health care.

Assessment of Article: Excellent review of Major Salivary Gland Agenesis and its contributing effects to the dentition.  It was helpful to review some of the signs and symptoms that suggest this disease in children.  Also important to note that children who have this may not complain of a dry mouth because it has always been that way and they have not point of reference to compare it to.

Orofacial Findings and Dental Treatment in an 8-year-old Patient With Trisomy 18: A Case Report

Resident Name: Todd Bushman
Article Info: Orofacial Findings and Dental Treatment in an 8-year-old Patient With Trisomy 18: A
Case Report

Main Purpose: The purpose of this article was to present the case of an 8-year-old
child diagnosed with trisomy 18 and address the clinical features observe, emphasizing
the disease specific oral, craniofacial, and dental findings.

Methods: An 8-year-old black female trisomy 18 patient was seen at the clinic of the Center of Formation of Human Resources São Paulo, Brazil. The child was referred to the authors’ service for general dental care by the University Hospital of Ribeirão Preto where she was undergoing medical treatment since the age of 5 months

Key Points: At age 8 the patient was unable to move or communicate, had remarkable feeding disabilities, and had accentuated failure to thrive. The patient also exhibited other clinical manifestations typically
observed in trisomy 18 individuals, such as malformation of superior and inferior limbs, clenched fi sts with the index finger overlapping the third and fourth digits.  Hypoplastic fingernails, rocker-bottom feet with prominent heels and arched soles, increased intermammillary distance, and joint contractures. The craniofacial findings included: microcephaly, prominent occiput, retroflexion of the head, low-set dysplasic ears, underdeveloped nose, micrognathia, and small mouth with limited mouth opening.

The child was at high risk for caries and caries activity.  Before each dental treatment appointment,
as a routine procedure, she was given a prophylactic antibiotic therapy of Clindamycin 600 mg  because the child was reportedly allergic to penicillin. Dental care for trisomy 18 patients is further complicated by their: severe intellectual deficit, limited communication skills, and reduced ability to cooperate with even simple procedures.  Therefore, the emphasis on the oral health management of these special needs children must be on prevention. The initial phase of the treatment plan was directed at providing the parents with elementary instruction on oral health care.  C was restored with resin composite after indirect pulp capping with calcium hydroxide cement and a glass ionomer base were provided. Teeth # 16 and 46 were sealed with
a resin-based sealant. In spite of the patient’s micrognathia, small mouth, and limited mouth opening, it was possible to carry out caries removal, cavity preparation, and restorative procedures under absolute isolation using a rubber dam. At the last session, dental prophylaxis was performed and topical fluoride was applied.

Assessment of Article:  The article was mainly about drawing attention to the disease and the fact that they have unique dental needs as do most special needs kids.  Because treatment is difficult without sedation prevention is key and educating parents is essential.

Chapter 26 - Oral Habits

Resident Name: Derek Nobrega
Pinkham 5th edition: Chapter 26 – Oral Habits
Authors: John R Christensen, Henry W Fields, Jr., Steven M. Adair

- A habit that has resulted in movement of the primary incisors or has inhibited eruption will affect permanent incisors if it is not eliminated, however the changes are not irreversible. If a habit is stopped during the mixed-dentition years the adverse dental changes will begin to reverse naturally, however some appliance therapy may be required.

- Majority of oral habits – 2/3 are ended by 5 years of age
- Dental changes vary based on intensity (forced applied during sucking), duration (amount of time spent sucking), and frequency (number of times the habit is practiced/day).
- Duration is most critical – 4-6 hours is minimum necessary to move teeth
- The most frequently reported dental signs are
            1. Anterior open bite
            2. Facial movement of upper incisors and lingual movement of lower incisors
            3. Maxillary constriction
- If parents or child do not want to engage in treatment, it should not be attempted
- Patient should be given opportunity to stop habit before permanent teeth erupt
- If treatment is initiated, it should happen between 4-6 years
- As long as habit is stopped before full eruption of permanent incisors, the eruption process will reduce overjet and open bite
1. Counseling – discussion between dentist and patient about the problems caused – best aimed at older children and may be feeling social pressure to stop the habit
2. Reminder Therapy – for those who desire to stop habit but need help. Adhesive bandage placed on finger to remind not to place in mouth, or bitter substance placed on fingers
3. Reward System – contract drawn up saying patient will stop within a certain time period and get a reward
4. Adjunctive Therapy – should be used for 6-12 months
            A. Elastic Bandage – usually applied only at night, loosely wrapped over the arm extending from below the elbow to above it. The mass prohibits patient from sucking fingers.
            B. Quad Helix – corrects posterior crossbite caused by maxillary constriction and serves as reminder to patient to not suck finger
            C. Palatal Crib – interferes with finger placement and sucking satisfaction. Used in children with no posterior crossbite. Eating, speaking and sleeping patterns may be altered and subside within 3 days to 2 weeks

- Dental changes are similar to changes created by thumb habits
- 90% ended before 5 years old, and 100% by age 8
- Usually easier to stop as pacifier can be discontinued gradually or completely withdrawn

- Lip licking and lip pulling are benign habits as far as dental effects are concerned – red, inflamed, and chapped lips and perioral tissue are most apparent signs
- Little can be done to stop these habits
- Most do not cause dental problems but lip sucking and lip biting can maintain an existing malocclusion
- Most common presentation of lip sucking is lower lip tucked behind maxillary incisors – proclination of maxillary incisors, retroclination of mandibular incisors, and increased overjet

Tongue Thrust – characteristic of infantile and transitional swallows – can sustain open bite but not create one - considered a finding and not a problem to be treated
Mouth Breathing – research not well-controlled
- Mouth breather due to mandibular posture, incompetent lips, nasal airway obstruction
- Weak association between mouth breathing and long lower face and maxillary constriction

- Rare in children younger than 3-6, manifestation of increased stress, no evidence that it can cause malocclusion or dental change other than minor enamel fractures – no recommended treatment

- Wear rarely endangers pulp by proceeding faster than secondary dentin is produced
- Can lead to masticatory muscle soreness and TMJ pain
- Causes – local (reaction to occlusal interference or high restoration), systemic (intestinal parasites, subclinical nutritional deficiency, allergies, endocrine disorder), and psychological (personality disorder or increased stress). Also children with musculoskeletal disorders and severely mentally retarded children commonly grind their teeth
- Treatment – occlusal interferences equilibrated, referral to appropriate medical personnel to rule out systemic problems, mouthguard. Rarely occlusal wear is so extensive that SSCs are needed to prevent pulpal exposure or eliminate tooth sensitivity

- 10-20% in mentally retarded population
- Biting of lips tongue and oral mucosa
- Should be referred for psychological evaluation
- Treatment – use of restraints, protective padding and sedation. Extraction of selected teeth may be necessary