Tuesday, March 26, 2013

Orthodontists’ Perceptions of the Impact of Phase 1 Treatment for Class II Malocclusion on Phase 2 Needs

Resident: Derek Nobrega
Title: Orthodontists’ Perceptions of the Impact of Phase 1 Treatment for Class II Malocclusion on Phase 2 Needs
Authors: GJ King, TT Wheeler, SP McGorray, LS Aiosa, RM Bloom, MG Taylor
Journal: Journal of Dental Research 78(11): 1745-1753, November, 1999

Main Purpose: To examine how orthodontists, blinded to treatment approach, perceive the impact of phase 1 treatment on phase 2 needs.

Background: Almost 23% of malocclusions in children aged 10-12 are Class II. The most appropriate timing for the treatment of Class II malocclusions is controversial. Some clinicians advocate starting a first phase in the mixed dentition, followed by a phase 2 in the permanent dentition. Others see no clear advantage to that approach and recommend that the entire treatment be done in the late mixed or early permanent dentition.

Methods: 242 class II subjects aged 10-15 were included in the randomized clinical trial. For each subject, video orthodontic records, a questionnaire, a fact sheet, and a ceph tracing were sent to five randomly selected reviewing orthodontists blinded to the subject group and study purpose. Reviewing orthodontists were asked to assess treatment need, general approach, need for extractions, priority, difficulty, and determinants.

Key Points:
- 95% of orthodontists agreed on treatment need.
- 84% agreed on treatment approach.
- 80% agreed on extraction need
- Previously treated patients were judged as less difficult and to have a lower treatment priority.
- The most highly ranked problems ranked by orthodontists for treating class II patients are overbite, dental class II relationship, overjet, skeletal, and crowding.
- The most common reasons for not selecting treatment are no need for treatment (45.7%), no cooperation expected (24.3%), and too early to begin treatment (15.7%).
- Orthodontists do not perceive phase 1 treatment as preventing the need for a second phase or as offering any particular advantage with respect to preventing the need for extractionss or other skeletal treatments in the second phase
- Orthodontists do view early class II treatment as an effective means of reducing the difficulty and priority for phase 2

This article presents a situation we see frequently. This study seems to indicate that phase 1 treatment doesn’t prevent the need for phase 2 treatment. Therefore, if we see an older patient for the first time with a class II that hasn’t had phase 1 treatment, there is still time to correct their malocclusion. Conversely, if we initiate phase 1 treatment on a younger patient, it is important to let the parents know that phase 2 therapy will also be required. There are many factors that can indicate phase 1 including orthodontist preference, severity of class II, and behavior. 

Posttreatment changes after successful correction of Class II malocclusions with the Twin Block Appliance

Christine Millis DDS and Kara McCulloch DMD

American Journal of Orthodontics and Dentofacial Orthopedics V118 Number 1

Main Purpose: Evaluate long term stability of correction using a phase one approach utilizing the twin block appliance to correct a class II malocclusion.

Methods: 28 full cups Class II patients were selected with ANB angle of 5 or great were selected.  The sample was 11 boys and 15 girls.  All were treated with a twin block with instructions to were it full time except brushing or eating.  Cephs were taken and analyzed at beginning of treatment at and 3 years post treatment.  The values were compared with 28 control patients matched for age and gender.

Key points:
  • Class I occlusion was achieved for all patients between 6 to 15 months
  • 2 patients could be located for the 3 year follow up 
  • There were 5 statistically significant findings; 4 of them were dental only.  The only skeletal finding was the ramus height measured from condylion to gonion
  • Mandibular body length was greater (5.2mm) compared to control (4.5mm)  but was not statistically significant. 
  • Molar relapse was an average of 1.2mm for the treatment group when compared to the control
  • Lower incisors were uprighted and overjet was reduced in the treatment group which is likely due to the fact that the molars were not allowed to drift forward to fill leeway space
  • What skeletal change was noted was stable after 3 years. 
Thoughts: This is a very technical, dry article with lots of ceph numbers in it.  Dr. Brennan will always say that we can't grow mandibles and this seems to support that.  Also, a twin block is incredibly uncomfortable and I would have trouble recommending it if there is not a better success rate. 

The effectiveness of protraction face mask therapy: A meta-analysis

Kyung-Hong Cal Kim

The effectiveness of protraction face mask therapy: A meta-analysis

Authors: Kim J, Viana M AG, Graber TM, Omerza FF, BeGole EA

American Journal of Orthodontics and Dentofacial Orthopedics Volume 115 Number 6


To increase sample size and provide stronger statistical support for conclusions drawn concerning the use of protraction face mask in Class III treatment

Background Information:
-Treatment of skeletal Class III malocclusion is most challenging because of unpredictable and potentially unfavorable nature of growth in patients.
-While it was traditionally believed that the Class III skeletal relationship results primarily through over-development of the mandible, maxillary retrusion is reported as the most common contributing component of Class III features.

-Meta-analysis of articles dated 1996 or earlier
-14 articles (11 English + 3 foreign language studies) met the inclusion criteria

-SNA, Wits, ANB, mandibular plane angle, upper incisor angle increase, lower incisor angulation decrease, and forward movement of A point during treatment with protraction face mask were definite trends noted in studies.
-Upper incisor angulation demonstrates greater proclination in the non-expansion groups
-All values of the younger group were larger than the older groups: greater tx effects in the younger group
-Same degree of improvement was obtained within a shorter period of time with the expansion appliance: Use of an expansion appliance enhances the protraction effect in terms of time with less dental effect
-More skeletal effect and less dental change with the expansion appliance, while more dental and less skeletal change is produced with the non-expansion appliance
-Protraction face mask therapy is still effective but to a lesser degree in growing patients older than 10 years of age

It was an interesting article, especially knowing that there are more recent studies that show that opening the sutures by palatal expansion has little to no effect in the rate of protraction by protraction face mask. It would have been nicer for this meta-analysis to be able to include more studies.

Orthodontics and temporomandibular joint internal derangement

Resident: Jeff Higbee
Article: Orthodontics and temporomandibular joint internal derangement
Journal: American Journal of Orthodontics and Dentofacial Orthopedics
Authors: Katzberg, R. MD, et al

To compare the prevalence of internal derangement of the TMJ in asymptomatic volunteers versus symptomatic subjects using MRI with a detailed comparison to clinical signs and symptoms and with attention to a prior history of orthodontic treatment.

-Study based of 178 subjects: 76 asymptomatic and 102 TMJ patients.
-Complete head and neck exam were done and any patients with symptoms of TMJ dysfunction were excluded from the study.

Key Points:
- No difference between asymptomatic volunteers and symptomatic subjects in relationship to prior orthodontic treatment.
- No relationship between a hx of orthodontic tx and TMJ disk displacement could be found (previously it was suggested that ortho tx is potentially related to TMJ disk displacement).
- A high prevalence of internal derangement in asymptomatic volunteers was shown but there was a statistically significant higher prevalence in symptomatic subjects.
- No association can be made between ortho tx and TMJ internal derangement.

Good article because we may have parents who ask about ortho causing TMJ problems. 

Article #36- Change in the width of the mandibular body from 6 to 23 years of age: an implant study

Resident: Matthew Freitas
Author: Haluk Iseri and Beni Solow
Journal: European Journal of Orthodontics 22 (2000)

-To examine whether there is increased transverse mandibular bone growth after the mandibular halves fuse, by using bilateral implant markers in the mandible
*Mandible is known to grow in vertical and sagittal direction

-Bilateral implants placed in the premolar region of the mandible of 10 subjects
-CT scans were used
-Observation period ranged from 8-16yrs; age interval 6-23years
-Measured the width between right and left side mandibular implant markers with digital calipers

-A small, but statistically significant increase in width was found; ranging 0.7-1.7mm
-Avg. total increase from 6-18yrs was 1.6mm (0.13mm/year)

-Mechanism of increase in width is unknown
-It is suggested that an increase in occlusal forces might influence bone remodeling in the mandibular body, thus producing or allowing gradual permanent outward bending of the mandibular halves

Eruption of the permanent upper canine: a radiologic study

Resident Name:  Todd Bushman
Eruption of the permanent upper canine: a radiologic study
Author: Fernández E, Bravo LA, Canteras M.
Journal: Am J Orthod Dentofacial Orthop. 1998 Apr;113(4):414-20.

Main Purpose: To gain a better understanding of the eruption patterns of maxillary canines.
They studied upper canine’s inclinations and its relation to the lateral incisor, on the basis of the panoramic radiographic records of 305 children aged 4 to 12 years. The study sample comprised 554 maxillary canines in the oral pre-emergence phase of eruption. Subject age, sex, inclination of the canine (CI), its relation to the lateral incisor (RCLI), and development of the lateral incisor (DLI) were evaluated.

Key Points: 

 - The results show that the canine erupts, increasing its inclination mesially until a maximum is reached, at about 9 years of age, after which the tooth begins to progressively upright itself.

 - The individual variability of the degree of CI at a given age is considerable and hard to predict.

 - In the initial stages, the lateral incisors are most commonly characterized by overlapping, a situation rarely seen in the final stages. They tend to straighten out and overlapping is rare.

 - The development of the lateral incisors effectively separates both periods, because when development is incomplete, more than half of the cases have an overlapping canine to lateral relationship.

 - In contrast, when the development of the lateral incisor is complete, this overlapping is seen in only 7% to 11% of the cases. This variable therefore increases the capacity to detect a possible eruptive anomaly at an early stage.

 - In patients with complete development of lateral incisors and overlapping canine to lateral relationship, particularly when associated with other clinical signs such as the nonpalpation of the cuspid bulge in the alveolar process, the presence of dental agenesis, ankylosis, malformations, or ectopic eruptions, extraction of the primary canine is advised to prevent impaction.

Assessment of Article: This article is important for us because we see many of these kids when the canines are forming. How we treat them while they are young greatly impacts the future development of their teeth.  We have the ability to intervene and avoid future complications

Management of lower incisor crowding in the early mixed dentition

Resident: Elliot Chiu
Title: Management of lower incisor crowding in the early mixed dentition
Author: Foley et al
Journal: Journal of Dentistry for Children 1996

Main purpose: To describe methods of managing lower incisor crowding

Key Points
-4 factors are key to managing crowding
1. Interdental spacing
2. Intercanine distance
3. Increase of arch perimeter
4. Size ratio between primary and permanent teeth
-By a dental age of 8.5 years, 85-100% of intercanine growth is complete ("once the laterals erupt, what you see is what you get")
-Primary interdental spacing of 6mm or more OR intercanine distance of 28mm or more will usually result in no crowding issues
-Increase in arch perimeter and size difference are important but difficult to predict/measure
Treatment options
-Crowding of less than 2mm? NO TX, crowding can resolve with growth and Leeway space
-Crowding of 3-4mm? DISC PRIMARY CANINES
-Crowding of >10mm? REFER FOR ORTHO

Great article. Simple, easy to understand. Good review for lower incisor crowding in the mixed dentition.

Wednesday, March 20, 2013

Long-Term Evidence for Favorable Midfacial Growth After Delayed Hard Palate Repair in UCLP Patients

Resident: Mackenzie Craik

Article: Long-Term Evidence for Favorable Midfacial Growth After Delayed Hard Palate Repair in UCLP Patients

Author: Hans Friede, DDS, Hans Enemark, DDS

Journal: Growth and Development in Orthodontics

Objective:  To investigate whether delayed hard palate repair resulted in better midfacial growth in the long term than previously achieved with “conventional” surgical methods of palatal closure.

Methods: Long-term cephalometric data from patients with unilateral cleft lip and palate were available from two Scandinavian cleft centers.  The patients had been treated by different regimes, particularly regarding the method and timing of palatal surgery.  Patients were analyzed retrospectively, and one investigator digitized all radiographs.

Patients: Thirty consecutively treated subjects from each center, with cephalograms taken at three comparable stages between 10 and 16 years of age.

Results and Conclusions:  Patients whose hard palates were repaired late (early soft palate closure followed by delayed hard palate repair at the stage of mixed dentition) had significantly better midfacial development than patients in whom the hard palate was operated on early with a vomer flap, and then during the second year of life, the soft palate was repaired with a push-back procedure.  As the growth advantage in the delayed hard palate repair group was accomplished without impeding long-term speech development, the delayed repair regimen proved to be a good alternative in surgical treatment of patients with unilateral cleft lip and palate. 

Assessment:  This was an interesting article although these outcomes are seem to directly contradict the approach we take with our NAM babies.  We schedule the first surgery in which the nose, lip, and premaxilla are repaired at around 4-6 months.  The following surgery to repair the hard and soft palate takes place at around 1 year.  


Pediatric Oral Surgery (264)
-Increased  risk for potential adverse effects on growth from injuries and/or surgery in the pediatric population
-Developing tooth follicles can complicate and alter the surgery; 3D imaging is recommended
-Tumors generally grow faster and are less predictable in children, however children are more resilient and heal more rapidly
-Infections of the upper portion of the face, patients usually complain of facial pain, fever, and inability to eat or drink.
-Infections of the lower face usually involve pain, swelling, and trismus.
-Permanent canines are second most impacted tooth, second to third molars. Impaction typically occurs when the cusp of the canine is mesial to the distal half of the root of the lateral incisor. One study found that 91% of ectopically erupting permanent canines normalized after extraction of the primary canines, when the starting position overlapped the lateral incisor less than half of the root. 64% normalized after primary canine extraction when overlap was more than half. If there is no improvement after 1 year, surgical intervention should be considered.
-Third moral removal is recommended before the middle of the third decade. Removal is ideal when the furcation has developed, but before complete formation of the roots.
-Supernumerary teeth more common in males and 10x more common in maxilla. Consider mesiodens when asymmetric pattern of max incisors or delayed eruption. Only 25% of mesiodens spontaneously erupt, making surgical intervention often necessary for their removal.
-Congenital epulis of the newborn is typically surgically excised.
-Mucoceles that are not shallow and do not resolve on their own, should be surgically treated.
-Maxillary frenectomy is recommended only after the permanent incisors and canines have erupted and the diastema has had an opportunity to naturally close.
-Lingual frenectomy should be considered when the patient can not stick their tongue out past their lips.

Acquired Tempromandibular Disorders in Infants, Children and Adolescents (258)
-TMJ experiences active growth in the first two decades and it undergoes adaptive remodeling changes throughout life.
-TMD is defined as functional disturbances of the masticatory system, and typically have multiple factors: trauma, open bite, >6mm overjet, functional crossbite, 5 or more missing posterior teeth, class III, grinding, clenching.
-One study found that 25% of patients had TMD signs/symptoms in the primary dentition. 2.7% had clicking in primary, 10% in transitional and 16% in the permanent dentition.
-Screening and Diagnosis: difficulty opening, noises during function, pain around ears and cheeks, pain when chewing, pain when when yawning, jaw lock.
-Palpate muscles and TMJ to evaluate tenderness. Evaluate jaw movements, range of motion, sounds, and radiographs (PAN, Lateral Ceph).
-Three classes of TMD: 1. Disorders of the muscles, 2. Disorders of the TMJ, 3. Disorders in other related areas that mimic TMD.
-Types of treatment: physical therapy, behavioral therapy, medication, occlusal appliances, occlusal adjustments, mandibular repositioning, ortho.
-A patient with suspected TMD should be referred to a specialist.

Surgical removal of an oral pyogenic granuloma and subsequent root coverage with a pedicle graft

Resident: Elliot Chiu
Title: Surgical removal of an oral pyogenic granuloma and subsequent root coverage with a pedicle graft
Author: Oliveira et al
Journal: Journal of Dentistry for Children 2008

Main purpose: Case report of an excision of a PG

Background Info
-PG is a lesion frequently arising on the gingival tissue
-Excessive reaction of connective tissue to stimuli or injuries
-Non-neoplastic proliferation of endothelial cells and bleeds easily
-DDX: Fibroma, peripheral odontogenic fibroma, peripheral giant cell granuloma
-Recurrence may be seen if lesion is not totally excised

Case Report
-7 yo Caucasian female presents with localized swelling on the anterior maxillary gingival tissue, which bled after brushing
-Incisional biopsy was done, biopsy confirmed PG
-Lesion excised, but root of #8 exposed
-Pedicle graft performed using the laterally positioned split-thickness flap from unerupted #9 to cover the root surface and alveolar bone.
-1 year follow up shows no recurrence of the PG and satisfactory clinical appearance of the receptor and donor gingival tissue sites

-Interesting case for a non-traditional PG excision.

Tuesday, March 19, 2013

Temporomandibular Joint Ankylosis Surgery in a Child: Case Report

Kyung-Hong Cal Kim

Temporomandibular Joint Ankylosis Surgery in a Child: Case Report

Authors: Presser Lima PV, Kramer PF, Ioppi L, Hoffmann R

Journal of Dentistry for Children 78:2, 2011

To report on the case of an 8-year-old girl who sought medical care for severe limitation of her mouth opening, without evident facial deformity.

Key Points:
-Condylar fractures (0.2%-0.4% of fractures) are the most common causes of articular ankyloses
-Rarely associated with pain
-Surgical treatment of TMJ ankylosis is quite complex and has a rather unpredictable prognosis, mainly in pediatric patients.
-Surgical treatment should not be indicated for most cases (maxillomandibular immobilization for 7-10 days + intense physical therapy)
-Ankylosis developed during childhood or at an early developmental stage is an articular disorder that causes severe facial deformity and poor occlusion.
-Limitation of mouth opening may also cause difficulties in speaking, opening the mouth, and chewing, occlusal disharmony, poor oral hygiene, rampant caries, generalized gingivitis, and periodontal disease

-8-year-old female patient
-Difficulties in opening her mouth since she was 3-years-old.
-Severe limitation of opening (7mm) + several carious lesions caused by the difficulty in performing adequate oral hygiene.
-Dx: unilateral TMJ ankylosis because of complete fusion between the mandibular condyle and the articular fossa of the temperal bone
-Tracheostomy due to inability to intubate the patient using conventional route
-Arthroplasty associated with ipsilateral coronoidectomy followed by  interposition of the temporalis muscle fascia (excellent growth and regeneration potential).
-Suture with 5.0 ethicon nylon thread.
-Active and passive physical therapy initiated 48 hours after the surgery to promote relaxation, analgesia, and gradual increase and maintenance of mouth opening.
-6 month tx w/ weekly follow-up
-Comprehensive dental tx within 3 months of the surgery.
-Mouth opening improved from 7mm to 27mm

Interesting case report regarding TMJ ankylosis. Considering how often authors mentioned the importance of “intense physical therapy,” I wish they elaborated more on what was included in the physical therapy regimen. I also found it interesting that they chose to intubate the patient via tracheostomy rather than nasoendotracheal intubation, if oral intubation was not possible due to limited opening.

Pinkham chapter 28 Local Anesthetsia and Oral Surgery In Children

Resident: Todd Bushman

Title: Pinkham chapter 28 Local Anesthetsia and Oral Surgery In Children

Local anesthesia in Children
 -Topical anesthesia – is used to lessen the pain from injection.  It is debatable how effective it is but most agree that in most injections it helps.

Operator technique is important in limiting the pain felt
-         - Verbal distraction
-         - Vibratory stimulation
-        - Cotton swab pressure
-        - One carp should take 1 minute to deposit

Max primary and permanent molar anesthesia – injection should penetrate the mucobuccal fold and be inserted to a depth that approximates the apices of the roots.

Max primary canines and permanent incisor and canine anesthesia – can either be given as an infiltration in the mucobuccal fold to the depth of the apices or an infraorbital block injection

Palatal tissue anesthesia – these are very painful and should only be used if necessary to get full palatal anesthesia.  Pressure can be applied to lessen the pain.

Mandibular tooth anesthesia – IA blocks can be used where the insertion is between the internal oblique ridge and the pterygomandibular raphe at the level of the occlusion.  If missed go slightly higher.  Long buccal can be used to anesthetize the buccal gingival.  Sore advocate the periodontal ligament injection but some evidence has shown this can cause hypoplasia and decalcification of succedaneous teeth.

Oral surgery in Children: considerations
-        - Obtain good medical HX
-        - Obtain appropriate medical and dental consultations
-        - Anticipate emergency situations
-        - Be prepared for emergencies
-        - Most prefer pedo forceps and name them kid friendly names
-        - Child and parent should be well prepared for the procedure and what to expect
-        - Throat guard or rubber dam should be placed to prevent aspiration.
-        - Support the jaw on mandibular extractions.
-       -  Separate the marginal gingiva, then luxate before forceps extraction.
     Max molar extractions: Root fracture is possible and likely with these teeth.  They should be luxated palatally first then buccally.

Maxillary anterior extractions:  rotational movement used to twist out.

Mandibular molar extractions:  Must support mandible, buccal palatal movement used to coax out.

Extraction of Mandibular anteriors:  Careful not to displace adjacent teeth due to conical roots.  Rotational force used to extract.

Root fracture:  A common sense approach must be taken.  If the root can be accessed and is visible then an effort should be made to extract it.  If the fragment is very small or inaccessible, or several attempts have failed, it is better to leave the root fragment.  Damage can be caused to the succedaneous tooth.

Soft tissue procedures

-Biopsies: If the lesion is less than .5cm an excisional biopsy is best.  Consideration must be taken if the lesion appears vascular and can be checked with aspiration.  Some areas such as the tongue may require sedation for biopsy due to the sensitivity of the tissue.  Resorbable sutures are preferred.

Max labial – should only be performed if after it has been shown that the frenum is a causative factor in maintaining a diastema.  This cannot be determined until the permanent canines have erupted.
Lingual Mandibular – only the most severe cases qualify and should only be considered after evaluation by a speech therapist.

Facial fractures: Look for the following signs:
- Altered occlusion
- Numbness in the infraorbital nerve distribution
- Double vision
- Periorbital ecchymosis
- Facial asymmetry
- Limited mandibular opening
- Subcutaneous emphysema
- Nasal bleeding
- Bruising of the palatal and buccal mucosa
- mobility or crepitus of maxilla

Management of a Dentigerous Cyst in a Child with Hereditary Angioedema

Resident: Jeff Higbee
Article: Management of a Dentigerous Cyst in a Child with Hereditary Angioedema
Authors: Renata Simoes Moraes, DDS, MS, et al
Journal: JournalofDentistryforChiidren-7:1, 2010
The purpose of this paper was to report the case of an 8-year-old girl with hereditary angioedema (HAE) who underwent 2 oral surgeries for removal of a dentigerous cyst without any significant episode of angioedema.
- One week after routine radiographic examination revealed an odontogenic cyst, short-term prophylactic therapy (Danazol 600 mg/day) was initiated to avoid an angioedema attack.
- The cyst was carefully removed under general anesthesia without life-threatening complications.
- Postoperative prophylactic therapy also was performed.
- Histopathological exam confirmed the diagnosis of a dentigerous cyst.
- Nine months after surgery, the cyst recurred and it was successfully removed once more under general anesthesia.
The case presented showed that the oral management of a pediatric patient with HAE is a high-risk procedure. It can be performed successfully, however, when the involved health professionals are aware of both the risks and preventive strategies.

Monday, March 18, 2013

Bilateral Dentigerous Cyst in a Nonsyndromic Patient: Case Report and Literature Review

Bilateral Dentigerous Cyst in a Nonsyndromic Patient: Case Report and Literature Review

Sérgio Elias Vieira Cury, PhD et al

Journal of Dentistry for Children-76:1, 2009

Main Purpose: Case report and literature review of a 5 year old boy who had biltaeral dentigerous cysts

Key Points:
  • Dentigerous cysts are the second most common cyst behind a radicular cyst and account for 24% of cysts
  • They are usually painless and appear as well defined, radiolucent lesions with a sclerotic border associated with an unerupted tooth
  • Most cysts are solitary with multiple cysts usually associated with developmental syndromes like mucopolysaccharidosis, basal cell nevus syndrome or cleidocranial dysplasia
  • A 5 year old boy presented with CC of bilateral swelling.  Radiographs showed two large radiolucent lesions. 
  • Patient was referred to a geneticist who found no remarkable findings.  There also was no family history of developmental syndromes
  • Cysts were enucleated under GA.  Compromised teeth were also extracted. Biopsy was taken and pathology confirmed diagnosis of dentigerous cysts
  • There have only been 18 cases of bilateral cysts in non-syndromic patients and most were associated with third molars
Assesment: Nice review on dentigerous cysts and their presentation.  It makes me think about how often times we just take bitewings but we really should be taking pans when we can to look for anything strange going on deep in the bones.

Wednesday, March 13, 2013

Case Report: Treatment of Mucocele of the Lower Lip With Diode Laser in Pediatric Patients: Presentation of 2 Clinical Cases

Resident: Mackenzie Craik

Article: Case Report: Treatment of Mucocele of the Lower Lip With Diode Laser in Pediatric Patients:
Presentation of 2 Clinical Cases

Author: Pedron, Galleta, et al.

Journal: Pediatric Dentistry, Nov/Dec 2010

Introduction: The term “mucocele” is used to define the accumulation of mucus secreted from salivary glands and their ducts in the oral cavity’s subepithelial tissue.  Clinically, a mucocele is characterized by an increase in volume, with a bubble-like shape that contains saliva, and is similarly colored to that of the normal mucosa or it may present blue coloration, depending on whether it is deep or superficial,  respectively.  The principle etiology of a mucocele is mechanical trauma, causing the rupture of a salivary duct and consequent mucus extravasation within the surrounding tissue.  Treatment options for mucoceles include surgical excision, marsupialization, micromarsupialization, cryosurgery, laser vaporization, and laser excision.

Cases/Management: Two boys age nine and ten presented with swellings in their lower lips.  Based on the clinical characteristics and history, mucocele was the initial clinical diagnosis for both
lesions. Removal of the lesions was performed under local infiltrative anesthesia using a diode laser at continuous mode in a contact technique.  Postoperative care included 0.15% benzidamine hydrocloride mouthwash 3 times per day for 1 week, and the patients were advised not to bite their lower lips to avoid recurrence of the lesion.  Both patients were followed until complete healing was achieved, which occurred in 30 days.  Extravasion mucocele was confirmed by the presence of mucus in the lamina propria, which was surrounded by inflammatory cells and an immature granulation tissue.  Marsupialization had resulted in considerably higher recurrence rates.  Treatment of mucoceles with a high-intensity diode laser provided satisfactory results in the 2 cases presented. As the incidence of mucoceles in children is relatively high, this technique may represent an improvement over other techniques and an adequate protocol for this lesion in a pediatric population. Appropriate power-set parameters must be considered for this type of procedure to avoid excessive thermal damage to the soft tissues and consequent unfavorable postoperative symptoms.

Assessment:  Interesting article about effectively treating mucoceles.  This is yet another example of a good use for lasers in the dental office.  Many pediatric dentists would probably refer this out, but it should be something that we could do in our own offices if we wanted to.

Tuesday, March 12, 2013

Clinical Considerations in the Management of Inflammatory Periodontal Diseases in Children and Adolescents

Clinical Considerations in the Management of Inflammatory Periodontal Diseases in Children and Adolescents

Resident: Todd Bushman

AuthorsLeyvee Cabanilla, DDM, MSD, DDS Gail Molinari, DDS, MS, MS

Purpose: The purposes of this paper are to present the periodontal diseases and conditions described in the 1999 workshop sponsored by the American Academy of Periodontology, review the risk factors for the development of periodontal diseases in the pediatric and adolescent populations, and present appropriate clinical periodontal assessment and management for these age groups.

Key Points: 
-Risk factors: Potential risk factors for developing periodontal diseases in the young population include: gender, race, level of oral hygiene; family's socioeconomic level; and other environmental factors.

-Several systemic diseases, a significant number of which are genetic disorders, are associated with periodontal destruction in children and adolescents

-Although periodontitis in the primary dentition is usually insignificant, young children with rare and profound systemic diseases, such as Papillon-Lefevre syndrome, hypophosphatasia, and leukocyte adhesion deficiency, are at risk from severe generalized periodontitis during or immediately after eruption of the primary teeth.

-Significant systemic stress such as malnutrition may also have an impact on the periodontium. 

-Despite the fact that periodontal diseases are among the most frequent diseases affecting children and adolescents, there still seems to be a lack of uniform protocol followed by dental clinicians in the assessment, diagnosis, and treatment of periodontal conditions in the young population. Current recommendations include: examination of gingival tissues; assessment of oral hygiene; detection of calculus; and periodontal probing of selected sites, particularly after the eruption of the permanent teeth.  Radiographic examination and assessment of deficiencies in the width of attached gingiva as well as areas of recession have also been recommended. It emphasizes the importance of children receiving periodontal examination as part of routine dental visits, since early diagnosis ensures the greatest chance for successful treatment. 

Assessment: This was a pretty dry article that just went over some of the periodontal diseases affecting kids and some of the factors that affect those diseases.  It is important to realize that this does affect our population and that it is not only an adult dental problem.

Periodontal Problems in Children and Adolescents

Kyung-Hong Cal Kim

Pinkham Chapter 24:

Periodontal Problems in Children and Adolescents

-Characterized by inflammation of the gingival tissues with no loss of attachment or bone
-Clinical signs: erythema, bleeding on probing, edema
-Younger children have less plaque than adults and appear to be less reactive to the same amount of plaque
-Gingivitis can occur in half the population by the age of 4 or 5 years
-Prevalence of gingivitis peaks at close to 100% at puberty
-Peak prevalence of puberty-associated gingivitis is at age 10 years in girls and 13 years in boys
-Is reversible and can be managed with improve oral hygiene

Gingival Enlargement
Chronic Inflammatory Gingival Enlargement
-May be localized or generalized
-Commonly occurs when plaque is allowed to accumulate around ortho appliances or in areas chronically dried by mouth breathing
-Enlarged interdental papillae and the marginal gingiva, tissue is erythematous and bleeds easily
-Gingivectomy is rarely required

Drug-Induced Gingival Enlargement
-Can occur after therapy with the anticonvulsant phenytoin (Dilantin), the immunosuppressant cyclosporine, or calcium channel blocker (nifedipine, nitrendipine)
-Painless, fibrous, firm, and pale pink, with little tendency to bleed
-Occurs first in the interdental region and may appear lobular
-Occurs slowly and may resolve to some degree when medication is discontinued
-Enlargement can be removed surgically, but will recur

Anatomic Problems
-Tx should be delayed until the permanent incisors and canines have erupted to allow natural closure of the diastema
-Tx should be postponed until the diastema has been closed if ortho tx is planned
-Restrictive lingual frenum should be treated if the child cannot protrude the tongue from the mouth or touch the tip of the tongue to the upper alveolar process

Localized Aggressive Periodontitis in the Permanent Dentition
-Formerly called localized juvenile periodontitis
-Loss of attachment and bone around the permanent incisors and first permanent molars
-Rapid attachment loss (3x the rate of chronic disease)
-Inflammation is not as extreme as that occurring in periodontitis associated with systemic disease
-Usually detected in early adolescence
-Prevalence: 1%, most commonly occurs in African-American population
-Linked to the presence of high numbers of A. actinomycetemcomitans
-Tx: Local management + systemic abx (systemic tetracycline, metronidazole w/ amoxicillin) and microbiological monitoring

Generalized Aggressive Periodontitis
-May affect the entire dentition and is not self-limiting
-Is NOT associated with the high levels of A. actinomycetemcomitans that occur in LAP
-Tx: aggressive management with local therapy as well as systemic abx

Localized Aggressive Periodontitis in the Primary Dentition
-Localized loss of attachment in the primary dentition as a result of bacterial infection + specific host immunologic deficits
-Most commonly in the molar area (bilateral, symmetric loss of attachment)
-Occurs most commonly in African-American population
-Can progress to LAP in the permanent dentition
-Tx: Local debridement + abx (tetracyclines contraindicated due to staining)

Necrotizing Ulcerative Gingivitis/Periodontitis
-Rapid onset of painful gingivitis with interproximal and marginal necrosis and ulceration
-Incidence peaks in the late teens and early twenties in NA and Europe
-Predisposing factors: Malnutrition, viral infection, stress, and lack of sleep
-Associated with high level of spirochetes and P. intermedia
-Tx: Local debridement + penicillin, metronidazole (with elevated temp)

Systemic Diseases and Conditions with Associated Periodontal Problems
Down Syndrome
-Trisomy 21
-Increased susceptibility to periodontitis (may occur in the primary dentition)
-Severity of periodontal destruction exceeds that attributable to local factors alone
-Various immune deficits (neutrophil function) may be responsible for increased susceptibility
-Severe recession in the mandibular anterior region associated with a high frenum attachment is common

-Enzyme bone alkaline phosphatase is deficient or defective
-Phenotypes: varies from premature loss of deciduous teeth to bone abnormalities leading to neonatal death (earlier the presentation of symptoms, more severe)
-Early loss of teeth is the result of defective cementum formation (teeth are affected in the order of formation): primary incisors are exfoliated before the age of 4
-No tx for the disease, but prognosis for permanent teeth is good

Leukocyte Adhesion Deficiency (LAD, aka generalized prepubertal periodontitis)
-Rare, recessive genetic disease (CD18 surface protein on leukocytes is defective or absent)
-Susceptible to bacterial infections, including periodontitis
-Diagnosis is usually made before dental symptoms appear
-Rapid bone loss around nearly all teeth, and marked inflammation

-Hematologic disorder characterized by reduced numbers or complete disappearance of neutrophils from the blood and bone marrow
-Increased susceptibility to recurrent infections
-Severe gingivitis and pronounced alveolar bone loss
-Cyclic neutropenia has been associated with oral symptoms in children

Papillon-Lefevre Syndrome
-Genetic disorder that is easily identified on clinical examination by the finding of hyperkeratosis of the palms of the hands and soles of the feet

-Infiltration of bones, skin, liver, and other organs by histiocytes
-in 10-20% of the cases, the initial infiltrates occur in the oral cavity (in the mandible)
-Gingival enlargement, ulceration, mobility of teeth with alveolar expansion, and discrete, destructive lesions of bone that can be observed on radiographs
-Teeth may appear to be “floating in the air” and eventually exfoliated
-Can initially be mistaken for LAP-Dx by biopsy
-Radiation and surgery to remove lesions, systemic chemotherapy for disseminated disease
-Prognosis for disseminated early-onset disease is poor, with mortality rates exceeding 60%
-Mild LCH has an excellent prognosis

-Most common form of childhood cancer
-ALL is most common, and has the best prognosis
-AML, but not usually ALL, may present with gingival enlargement caused by infiltrates of leukemic cells
-Lesions are bluish red and may sometimes invade bone
-Patient may have fever, malaise, gingival or other bleeding, and bone or joint pain

Periodontal Examination of Children
-Gingival tissues should be examined for redness, edema, bleeding, or enlargment
-Calculus is found in about 10% of children and approximately 1/3 of teenagers (most common areas are lingual surfaces of mandibular incisors, buccal surfaces of the maxillary molars)
-Probing of the permanent incisors and first permanent molars provides a diagnostic screening for LJP

Periodontitis as manifestation of Crohn's Disease in primary dentition: a case report

Resident: Elliot Chiu
Title: Periodontitis as manifestation of Crohn's Disease in primary dentition: a case report
Journal: Journal of Dentistry for Children 2004
Author:Sigusch et al
Main purpose: To describe an initial perio manifestation of Crohn's disease

 Background Info
-Crohn's disease is an inflammatory bowel disease of unknown etiology
-CD can affect any part of the GI tract, but typically affects the terminal segment of the small intestines and first segment of the large intestines
-CD often develops during childhood
-Oral lesions seen in 60% of all cases

Case Report
-6yo boy complains of diffuse swelling of the upper lip in the morning
 IOE: bleeding on probing, edema, erythema
-Radiograph: no alveolar bone loss
-Actinobacillus actinomycetemcomitans was isolated from subgingival sites
-Dx of localized aggressive periodontitis was made based on AA
-Tx: SRP and application of metronidazole and amoxicillin were unsuccessful
-Metabolic and immunological tests showed values WNL
-2 months after the first periodontal signs, the child suffered from severe malnutrition, diarrhea, and abdominal pain. Active colitis with multiple granulomas was detected with biopsies.
-Dx of Crohn's disease was made by internalist

Good, simple review of Crohn's disease. It is important for us to remember to rule out any systemic conditions when we see abnormal oral findings as we may be the first ones to see these signs.

Periodontal Diseases and Conditions (Chapter 6).

Resident: Mackenzie Craik

Article: Periodontal Diseases and Conditions (Chapter 6).

Author: Ann Griffen and Purnima Kumar

Publication: The Handbook of Pediatric Dentistry

Key Points:  -Drug induced Gingival Enlargement results from the use of 1) phenytoin (Dilantin), 2) Cyclosporin (immunosuppressant), 3) Calcium Channel Blockers. 
-Pyogenic Granuloma (Pregnancy tumor)- painless localized gingival enlargement, blue red color, occurs in pregnancy. 
-Pericornitis- Inflammation of gingiva covering partially erupted tooth, most common around erupting 3rd molars.
-Aggressive Periodontitis (Formerly “Early Onset Periodontitis)
            -Localized Aggressive Periodontitis in the primary dentition (formerly known as prepubertal periodontitis. 
                        -Attachment loss and bone loss around primary teeth
                        -Affects only some of the primary teeth.
                        -Most commonly affects primary molars
            -Dental Management
                        Combination of scaling and root planning and systemic antibiotics.
Periodontitis as a Manifestation of Systemic Diseases
                        -Genetic Disorder
-Phenotypes range from premature loss of deciduous teeth to severe bone abnormalities leading to neonatal death.
-Pulp chambers may be abnormally large.
Langerhans Cell Histiocytosis (formerly Histiocytosis X)
-Group of disorders with variable symptoms resulting from abnormal proliferation and dissemination of histiocytic cells of the Langerhans system
            -About 10% show oral involvement.
Development or Acquired Deformities or Conditions
            -Mucogingival Defects
                        -Pocket depth exceeds width of attached keratinized gingiva
                        -Lower incisor most common location
-In children defect may result from labial positioning of tooth erupting through band of attached gingiva.
            -Localized areas of gingival recession (“stripping).
                        -usually due to labial malposition of the tooth
                        -most common in lower incisors
                        -may be difficult to clean
                        -may produce mucogingival defect.