Wednesday, May 29, 2013

Temporomandibular Disorders: A Review of Current Understanding

Resident: Mackenzie Craik

Article: Temporomandibular Disorders: A Review of Current Understanding.

Author: Burton H Goldstein, DMD, MS

Publication: Oral Surgery, Oral Medicine, Oral Pathology Vol. 88, No. 4, Oct. 1999.

Objective of Article: The purpose of this article is to conduct a narrative review of current evidence regarding the understanding, evaluation, management, and treatment of TMJ disorders to provide a broad perspective and updated introduction to an important and controversial subject with rapidly changing developments and limited well-designed research.

Data Sources: Studies were identified through a search of MEDLINE for 3 topics: TMJ disorder, TMJ, and chronic pain.  This search was conducted over a 10 year period.  

Study Selection: More than 5000 articles were produced.  In-depth review of all of this literature was beyond the scope of the present article, which is intended to provide an overview.  The amount and diversity of the literature and the limitations of covering such a broad topic being recognized, the papers selected were those that reviewed limited topics or studied focused areas.  This report is not a systematic  or meta-analysis review.  An acknowledged limitation of this narrative review method lies in the potential for bias in selection.  The referenced works do not include all papers reviewed: only pertinent literature and reviews with comprehensive references were selectively included.

Conclusions: Advances in basic and clinical science have resulted in important changes in the understanding and management of TMJ disorders.  Many treatments are not supported by research, and the role of dentistry is changing to a more diagnostic and management-based model from the hands-on treatment procedures of the past.  The present science-based understanding of biopsychosocial disorder is important in properly and responsibly dealing with patients with TMJ disorders.

Herpesvirus Infection

Classic 100: #52
Resident: Matthew Freitas
Author: M. Greenberg, DDS
Journal: Infectious Disease and Dentistry 40:2, 1996

Purpose: This article reviewed the virology and general characteristics of herpes infection.

-There are more than 80 known viruses of the herpes group.
-The 7 known to infection humans include:
1. Herpes simplex virus 1 (HSV 1)- frequently transmitted by saliva, causes a majority of cases of oral, pharyngeal, eye, and CNS infections. Peak infection period between ages of 2 and 3yo. Symptoms include upper respiratory viral infection, fever, chills and nausea and lymph involvement. Followed by vesicles and ulcers of the oral mucosa. 20% have recurrent infections found on the labial tissue.
2. Herpes simplex virus 2 (HSV 2)- typically genital secretions and causes a majority of genital and anal infections. Infection period is typically when the patient becomes sexually active.
*Tissue cultures and blood tests for both HSV 1 and 2 can confirm viral infection.
3. Vericella-zoster virus (VZV)- primary infection (chickenpox), recurrent infection (shingles). Shingles typically occurs in older patients or immunocompromised. The virus can be fatal. Acyclovir is used at 4x the strength compared HSV treatment.
4. Cytomegalovirus (CMV)- frequent cause of asymptomatic infection in humans. Clinical presentations is rare except in neonates and immunocompromised patients. Transmitted by birth, saliva, blood or sexual. Symptoms include hepatitis, pneumonia, lymph and spleen involvement, myocarditis. Confirmed with viral culture from the tissue lesion.
5. Epstein-Barr virus (HHV 7)- transmitted by saliva/blood. Primary infection seen in childhood with subclinical symptoms or in young adults that causes mononucleosis. Clinical symptoms may not appear for up to 8 weeks. Lymph nodes and spleen involvement are very common. Diagnosis is usually with a blood test (increased lymphocytes).
6. Human hepres virus 6 (HSV 6)- transmitted by saliva, typically causes roseola. Virus has an affinity for CD4 lymphocytes.
7. Human Herpes virus 7 (HSV 7)- transmitted by saliva, recently discovered, no clear/specific clinical symptom associated with the virus. Also associated with CD4 cells.

Future caries susceptibility in children with early childhood caries following treatment under general anesthesia

Resident: Derek Nobrega
Title: Future caries susceptibility in children with early childhood caries following treatment under general anesthesia
Authors: Almeida A, Roseman M, Sheff M, et al.
Journal: Pediatric Dentistry. 2000. 22:302-306

Main Purpose:
To assess the susceptibility of children to the future development of caries following comprehensive treatment for ECC under GA.

42 patient aged 1.9-4.9 years old diagnosed with ECC were treated in the OR under GA. 31 caries free children were in the control group. Recall for both groups was every 6-9 months over a 2 year period. New carious lesions were recorded as new smooth surface caries and new put and fissure caries. Parents of children in the ECC group were given dietary counseling, OHI, TBI, general dental education and regular recall visits.

- 79% of ECC children had caries at recall visits vs. 29% for the caries-free control group.
- 17% of ECC children required re-treatment under GA within 2 years following their initial full mouth rehab.
- By 24 months ECC children had a mean 3.2+/-3.3 new carious lesions vs. only 0.8+/-1.6 in the control group.
- Prevalence of new smooth surface caries in the ECC group was 60% and significantly higher than the control group, at 13%.

This article is especially important for us at St. Joe’s since we see so many OR cases. It is important to remember that even with personalized instructions and regular follow up, many of the children we treat in the OR will have caries again in the near future. We must strive to prevent the return of these patients to the OR, and this can only occur through improved preventative measures and meaningful discussions with parents in order to stop this preventable disease process. 

Periodontal and Soft-Tissue Abnormalities

Resident: Todd Bushman
Article: Periodontal and Soft-Tissue Abnormalities
Author: Jayne E Delaney DDS, MSD

Main Purpose: Review different periodontal conditions in pediatric patients and how to treat them. It also covers some of the soft tissue lesions.

Key points :

Periodontal problems of the preschool child:

Localized and generalized periodontitis.  6-7% of children approximately age 5 have been shown to have radiographic periodontal bone loss. Treatment is scaling and root planning as well as antibiotics as needed.
Prepubertal Periodontitis – Usually seen inconjunction with systemic diseases. Most successfully treated when localized.
Neutropenias - Neutrophils play a protective role in the periodontium. In their absence, disease and bone loss can occur quickly; ulcers are a common occurrence. Treatment is scrupulous oral hygiene and antibiotic therapy.
Papillon-Leferve Syndrome – This is usually manifested in hyperkeratosis on the palms and soles of teeth and premature loss of teeth are common manifestations of this disease. Primary teeth are often lost by age 5. A treatment modality that has shown some promise is the endulate the child, treat heavily with antibiotics and allow later eruption of any unerupted teeth, which can erupt into an oral environment lacking in periodontal bacteria.
Metabolic disorders - Diabetic children may manifest with early periodontal disease due to altered neutrophil chemotaxis.
Histiocytosis X - aka Langerhans cell disease. Mostly a radiographic finding of "teeth floating in space" but gingival inflammation is also common.
Hypophosphatasia - Most common oral finding is early loss of teeth, sometimes with primary tooth exfoliation at age 1 and a half.

Soft Tissue problems:
Ankyloglosia - Most children will have some frenum growth with age, but others may need surgical intervention. A speech pathologist should be consulted in any case affecting speech and before any decision for surgery.
Geographic tongue - Asymtomatic and most common in girls.
Fissured tongue - Associated with geographic tongue, also benign.
Retrocuspid Papillae - Present in most children behind the mandibular cuspids. Not anything to worry about.
Gingival Fibromatosis - Can be drug induced, inherited or associated with leukemia. Poor OH exacerbates this problem.
Hemangioma - Benign tumor of mesenchymal origin. Usually painless. Surgical removal is the usual treatment.
Lymphangioma - Benign tumor of lymphatic origin. Usually present at birth. Tongue is the most common site.
Mucocele - Retention of mucous in subepithelial tissues, most common in children and adolescents. Treatment of choice is surgical removal.
Fibroma - One of the most common benign lesions. Treatment is surgical removal with low recurrence.
Parulis - End point of draining sinus tract associated with an abcessed tooth.
Herpesvirus Infection: viral infection
Herpangina - Acute viral infection usually in summer or early fall. Usually has vesicles on tonsillar fauces.
Hand-Foot-and-Mouth Disease - Caused by coxsackie. Ulcerating and crusting vesicles, treatment is palliative only.
Recurrent Apthous Ulceration - Cause is unknown, but suspect food allergies, trauma, stress and hormonal changes. Mouthrinse and topical anesthetics are treatment.
Candidiasis - Treat with topical application of antifungals.
Impetigo - Perioral purulent bacterial infection. Usually due to strep A or Staph aureus; treat with topical or systemic antibiotics.
HIV - Usually children will present with candidiasis. Parotid swelling is also more common in HIV children than adults.
Leukemias - Leukemic gingival enlargement is most common. But mucositis is also common due to chemotherapy associated with leukemia. Poor OH can really worsen the situation.
Traumatic Ulcer – The most common ulcer in children. Often seen with post-anesthesia bites.

Assessment:  Great article with good pertinent information regarding lesions and conditions we will see on a regular basis.  It is good to familiarize ourselves with them.

Hepatitis C Virus Infection: Review and Implications for the Dentist

Kyung-Hong Cal Kim

Hepatitis C Virus Infection: Review and Implications for the Dentist

Authors: Lodi G, Porter SR, Scully C

Oral Surgery Oral Medicine Oral Pathology Volume 86, Number 1

To review the current literature on hepatitis C virus infection, with particular attention to the aspects of interest for dental health care staff

Authors searched original resesarch and review articles on specific aspects of hepatits C virus infection

Background Information:
-Hepatitis C virus was identified for the first time in 1989
-A positive-stranded RNA virus
-Because of frequent errors in its course of replication and lack of repair mechanisms, HCV has an extremely variable genome and is present as quasispecies in a single infected person

-Highest known frequencies of HCV infection have been found in developing countries, particularly in Africa and the Middle East
-Retrospective study estimated that in the US during the last decade 150,000 subjects have been infected per year

-The principal route of transmission of HCV is parenteral, through contaminated blood
-Any recipient of blood or blood products, particularly before 1990, may be considered at risk of HCV infection
-Estimates from the UK, France, and Austrailia indicate that 6,000, 100,000, and 200,000 persons, respectively, have acquired infection after blood transfusion in those countries
-At present in the US the chance of becoming HCV-infected with a blood donation that passed all the screening tests is 1 in 103,000
-Transmission of HCV from health care workers to patients is rare
-Persons with histories of injecting drug use are at high risk of HCV acquisition
-A recent study showed the use of noninjecting drugs, such as intranasal cocaine, to be an independent risk factor for HCV infection
-A contaminated hollow needle may be a source of HCV infection in instances of accidental injury
-Although viral genome has been detected in semen and vaginal discharges, sexual route has a low efficiency of transmission that increases with length of relationship, chronic disease, and co-infection with HIV or other viruses
-Vertical transmission occurs infrequently, and breast-feeding is probably not an at-risk activity

-Gold standard in the diagnosis of HCV infection is the detection of the viral genome by means of RT-PCR
-Normal ALT values cannot exclude liver injury

HCV-related Liver Disease:
-Acute hepatitis C occurs in a minority of infected patients 6 to 12 weeks after acquisition of the virus, and symptoms include malaise, anorexia, and nausea
-Infection with HCV tends to cause chronic hepatic disease (hepatic cirrhosis is a common consequences)
-Except in the late stages of disease, chronic hepatitis C is usually an asymptomatic disease, often with normal or minimally elevated ALT
-Patterns of progression may be influenced by patient characteristics, such as gender, age, and immunologic status, by viral factors, or even by route of acquisition
-Thyroid disease may affect more than 10% of patients with chronic HCV infection
-High prevalence of diabetes mellitus has been reported in HCV disease

-Spontaneous resolution of chronic HCV infection is rare
-Current treatment of choice is INF-a (3 million IU administered subcutaneously 3x/week for 6 months)
-Antivial effects of INF-a include activation of cellular ribonucleases and inhibition of viral penetration and transcription
-Predictors of long-term response to INF-a therapy include infection with HCV genotype 2 or 3, serum viral levels below 1 million copies per ml, absence of cirrhosis, low quasispecies' heterogeneity, and low hepatic iron content

Impact of Advances in Diabetes Care on Dental Treatment of the Diabetic Patient

Brian L Mealey DDS
Compendium Vol. 19 No. 1; January 1998

Introduction: Review of Diabetes causes, treatments, and management of diabetic patients in a dental setting.

Key Points:
  • Diabetes is classified as a metabolic dysregulation primarily of carbohydrate metabolism
  • Most cases are primarily caused by problems with insulin production or function
  • Healthy people usually have blood glucose levels rangings from 60 mg/dl to 150 mg/dl
  • 7% of the population has diabetes and $1 in every $7 spent on health care is spent on diabetes related conditions
  • Common complications include blindness, kidney failure, heart attack, strok, and peripheral vascular disease often resulting in amputations
  • In 1985 a randomized clinical trial showed that frequent insulin injection combined with frequent monitoring of gluces levels significantly decreased serious complications.  This has since become heavily implemented.
  • Management of diabetes primarily consists of insulin and oral medications to maintain glucose levels at a healthy level.
  • Patients may check glucose levels four or more times per day.  A1C levels are also becoming useful in providing a longer view of glucose levels
  • Patients who become hypoglycemic may develop serious symptoms like coma or seizure
  • Treatment consists of eating gluose or injection with glucagon if patients are not able to take oral substances
  • Hyperglycemia is much less common
  • Patients should be encouraged to check glucose levels before dental appointments and dental providers should be able to manage and assist patients in a diabetic emergency.
  • Appointments should be kept at a reasonable length and patients should be encouraged to stop procedures and check glucose levels if they begin to feel symptomatic
  • Appointment times should be scheduled when glucose levels are most stable
Thoughts: Nice review on diabetes. I wish it could have spoken more about pediatric patients as the article was written for management of adults with diabetes.

Premature Exfoliation of Teeth in Childhood and Adolescence

Resident: Jeff Higbee
Article: Premature Exfoliation of Teeth in Childhood and Adolescence
Journal: Growth and Development and Orthodontics
Authors: James K. Hartsfield, Jr., DMD, PhD

Purpose: To review premature loss or marked loosening of primary teeth in the child and permanent teeth in the adolescent.

Conditions in which premature exfoliation in common:
- Hypophosphatasia
- Early-onset periodontitis (aggressive periodontitis)
- Prepubertal periodontitis (localized aggressive periodontitis)
- Juvenile periodontitis
- Papillon-Lafevre syndrome
- Singleton-Merten syndrome
- Hajdu-Cheney syndrome

Conditions in which premature exfoliation occur occasionally:
- Ehlers-Danlos syndrome
- Down syndrome
- Chediak-Higashi syndrome
- Hyperthyroidism
- Leukemia
- Langerhans-cell histiocytoses
- Neutorpenia
- Mandibuloacral dysplasia
- Metaphyseal dysplasia

Although the premature loss of primary teeth in conjunction with early eruption may be of no clinical significance, the loss of primary or permanent teeth in the absence of trauma should not be overlooked.  Lewis A. Barnes, MD states that “The loss of teeth in children younger than 5 years of age should suggest a genetic or systemic disease in the absence of trauma”.
Assessment: This was a good informative article with a lot of information.  A good review of several syndromes and diseases.

Tuesday, May 28, 2013

Dental Implications and New Guidelines for Antibiotic Prophylaxis

Resident: Elliot Chiu, DMD
Title: Dental Implications and New Guidelines for Antibiotic Prophylaxis
Journal: ?? April 1998
Author: Epstein et al
Main purpose: Review of AHA guidelines
Background info
-IE is a rare condition - incidence is 11-50 cases / million
-Incidence of bacteremia: extractions (51-85%), prophylaxis (0-40%), endo (0-5%), brushing (0-26%), flossing (0-58%), mastication (17-51%)

*AHA no longer recommends premedication for heart murmurs and mitral valve prolapse (with or without regurgitation)

1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
2. Previous infective endocarditis
3. Congenital heart disease (CHD)
   a. Unrepaired cyanotic CHD, including palliative shunts and conduits
   b. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
   c. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
4. Cardiac transplantation recipients who develop cardiac valvulopathy

Wednesday, May 8, 2013

The Validity of Maxillary

Resident: Matthew Freitas
Author: Y Nimkarn
Journal: Angle Ortho 1995;65 (5); 321-326

Purpose: The purpose of this investigation was to examine the validity of Pont's index, Schwartz analysis and McNamara's rule of thumb for predicting arch width expansion to alleviate crowding.

Pont's Index: Sum of the max incisor widths (SI: Sum of Incisors) and the width of the dental arch.
Formula: Premolar width requirement: SI/0.80
                Molar width requirement: SI/0.64
Schwartz analysis:
Narrow Face: First premolar SI+6mm, intermolar SI+12mm
Average Face: PM SI+7mm, intermolar SI+14mm
Broad Face: PM SI+8mm, intermolar SI+16mm
McNamara proposed a simple measurement for intermolar width in males of 37.4mm and females 36.2mm.

Methods: Records of 20 males and 20 females; permanent dentition, Caucasian, no previous ortho tx.
Crowding index calculated.
Three analysis were calculated for each patient.

Discrepancy for each: predicted width - actual width

1. Males had more significant correlations between arch width and crowding than females
2. Interpremolar widths were more strongly correlated than intermolar widths
3. Pont's index and McNamara's rule of thumb overestimated required arch width by 2.5-4.7mm and 2.7-3.7mm respectively
4. Schwartz's analysis overestimated interpremolar width by 2.5-4.3mm

Discussion: The results suggest that these indices potentially overestimate the arch expansion required to alleviate crowding. We should all take this into consideration when using any of these measurements for space analysis.

Skeletodental changes in the adolescent accruing from use of the lip bumper

Kyung-Hong Cal Kim

Skeletodental changes in the adolescent accruing from use of the lip bumper

Authors: Werner SP, Kumar Shivapuja P, Harris EF

The Angle Orthodontist Vol. 64 No.1 1994

To measure the effects of lip bumper treatment on development of the dental arches using a single appliance design and s single practitioner, and to evaluate the post-treatment stability of results obtained with the lip bumper followed by fixed mechanotherapy

Background Information:
-Purpose of the lip bumper appliance is to reduce lower anterior crowding, increase arch circumference, and move the permanent molars distally
-Use of lip bumpers may shorten treatment time and enhance stability of the result
-Increase in arch circumference is due in large part to increase in arch width

-Study models and standardized lateral cephalograms of 32 patients
-Skeletal or dental Class I or II with normal vertical dimensions
-4-8mm crowding in the lower incisor region
-Mean tx time: 2.0 years (range 0.3 years to 4.3 years)

-Significant increases in arch width at the canine, premolar, and molar regions
-No change at arch depth
-Significant decrease (avg=3.8mm) of incisor irregularities
-Significant increase in IMPA (avg=2.4 degrees)
-Observed mesiodistal repositioning and change in axial inclination (uprighting) in mandibular first molars
-None of the variables had a significant association with time in treatment

-The lip bumper can be used effectively to obtain expansion and decreased incisor irregularity in the mandibular arch
-The lip bumper caused the lower permanent molars to upright rather than to move bodily

Dental Care of the Pediatric Patient with Splenic Dysfunction

Marcio A da Fonseca DDS

Pediatric Dentistry 24:1, 2002

Main purpose: review of splenic dysfunction and its impact on dental treatment

Key points:
  • Spleen plays a major role in the immune system and contains about 25% of lymphoid tissue.
  • The spleen has complicated vasculature and recieves about 5% of cardiac output
  • Due to its intrigal role in immune response, patients with splenic dysfunction should be considered immunodeficient
  • Various causes of splenic dysfunction include SSA, malaria, irradiation, surgical removal, or congential absence.
  • Removal of the spleen is very dangerous as the body cannot mount appropraite immune response and is fatal in 50% of children and 33% of adults
  • Prevention of infection is paramount.  Vaccinations consideration should be given to repeat every 5 years instead of 10. 
  • Patients should be considered high risk and should be monitored closely by  medical professionals
  • Prophylaxis is controversial as studies have not shown it to be overly effective and may reduce the natural ability to fight infection
  • Dental considerations include avoiding other potentially infectious patients and close consult with medical professionals
  • ANC <1000 should have treatment defered
  • Pulpally involved teeth should be considered for extraction rather than vital pulp therapy
  • Above all, treatment should be accomplished quickly and with consult from medical professionals

Longitudinal Growth Changes in the Sagittal Relationship of Maxilla and Mandible

Resident: Elliot Chiu, DMD
Title: Longitudinal Growth Changes in the Sagittal Relationship of Maxilla and Mandible
Author: Nanda, et al
Journal: American Journal of Orthodontics 1995

Main Purpose: To describe longitudinal growth changes

-Cephs of 86 subjects (40 females/46 males) were taken and analyzed at 6,12,18,24 years
-A point, B point, Pogonion, Pterygomaxillary fissure, Sphenoethmoidal suture

-Between the ages of 6-24 years, there was a total growth increment of 6.07, 7.53, and 11.17mm for A, B, and Pog in females
-9.49, 11.65, and 16.21mm in males
-Males showed greater overall growth
-Percentage of growth increments relative to each point was approximately the same for both males and females
-Considerable individual variation was noticed for most subjects
-This variation continues to raise questions about growth prediction and its application

-This was an informative article, but very dry with many cephalometric numbers. The authors concluded that it is difficult to predict skeletal growth with so much variation between subjects.

Growth and Development and Orthodontics

Resident: Jeff Higbee
Article: Growth and Development and Orthodontics
Journal: American Journal of Orthodontics and Dentofacial Orthopedics

Dental Evolution
- Variations in tooth number, size, and morphology among and within population have provided insights in to the genetic basis or odontogenesis.
- Teeth probably originated as dermal structures called “odontodes” which subsequently migrated into the mouth and became associated with bones.
- Initially, teeth were identical conical spatially separated dental units (homodonty).
- Teeth are vertebrate-specific and within vertebrates, species-specific.
- Tooth shape varies with position in the jaws and is bilateral and symmetric.
- Phylogenic changes in dentition correlate with functional adaptation.  Teeth and teeth baring bones evolve together.
- A reduction in tooth number and size is a continuing evolutionary trend and it has been suggested that one incisor, one canine, one premolar, and two molars per quadrant is likely to be the dental profile of future man.

Tooth Agenesis
- There are over 60 syndromes that are associated with tooth agenesis.
- There are also somatic diseases such as syphilis, scarlet fever, rickets, or nutritional disturbances which are associated with tooth agenesis.

Theories on Tooth Agenesis
- Butler’s theory (1939) attempts to explain why certain teeth fail to form more than others. 
- Some have observed that the terminal or most posterior tooth of a tooth series is missing most frequently
- Some suggest the selectivity of tooth agenesis in terms of anatomic rather than an evolutionary model.
- Kjaer explained the location of tooth agenesis by neural developmental fields in the jaws.  The region within a single field where innervation occurs last is more likely to manifest tooth agenesis.

Familial Tooth Agenesis (FTA)
- This is a clearly recognizable, well-defined, relatively common dental anomaly
- Since 1980, methods in DNA cloning and sequencing, discovery of genetic markers across the human genome, and other sophisticated analysis have made it feasible to map inherited conditions like FTA
- These methods have provided evidence that FTA is genetically heterogeneous, suggesting that more than one gene defect contributes to the clinical variability of this dental condition.

This was good article with a lot of information.  There are many factors to tooth development, morphology, and agenesis.  More info is needed to better understand these anomalies. 

Management of Space Problems in the Primary and Mixed Dentitions

Resident: Mackenzie Craik

Article: Management of Space Problems in the Primary and Mixed Dentitions.

Author: Ngan, Alkire, Fields

Journal: JADA, Vol. 130, Sept. 1999.

Goal of Article: To update clinicians on the current knowledge of space maintainers.

Key Points:
-Proper management of space in the primary and mixed dentitions can prevent unnecessary loss in arch length. 
-Diagnosing and treating space problems requires an understanding of the etiology of crowding and the development of the dentition to render treatment for the mild, moderate and severe crowding cases. 
-Most crowding problems with less than 4.5 mm can be resolved through preservation of the leeway space, regaining space or limited expansion in the late mixed dentition.
-In cases with 5-9 mm of crowding, some can be approached with expansion after thorough diagnosis and treatment planning.  Most of these cases will require extraction of permanent teeth to preserve facial esthetics and the integrity of the supporting soft tissue.
-Serial extraction or guidance of eruption is reserved for treatment of severe tooth-size/arch-size discrepancies. 
-Due to variations in the timing and extraction sequence depending on the diagnosis, serial extraction should be reserved for those who can complete the treatment successfully.
-The recommended timing of referring patients with moderate crowding to specialists for treatment is in the late mixed-dentition stage of development. 
-Patients with severe crowding will require earlier evaluation for serial extraction.

Assessment: I thought that this was a really good article, one that is completely pertinent to us, and all the space maintenance we will be doing over the course of our careers.  This was just a good refresher and overview of different techniques we use to maintain space depending on the amount of crowding.

Tuesday, May 7, 2013

Pediatric bone marrow transplantation: oral complications and recommendations for care

Resident: Derek Nobrega
Title: Pediatric bone marrow transplantation: oral complications and recommendations for care
Authors: MA da Fonseca, DDS, MS
Journal: Pediatric Dentistry. 1998 Nov-Dec;20(7):386-94

Main Purpose: To discuss the important and unique role that pediatric dentistry has in the BMT team to help bring about a successful outcome through the prevention and treatment of acute oral complications seen in these patients.

Background: Bone marrow transplantation has become increasingly common for those that have a disease that affects the bone marrow directly or indirectly. Because of the level of immunosuppresion achieved in BMT, any problem the patient presents in the oral cavity can become life-threatening and increase the length of the hospital stay, the patient’s discomfort, and the treatment costs.

Pretransplant Oral/Dental Evaluation
Pediatric dentist’s goals when evaluating pre-BMT transplant are the identification, elimination, and prevention of potential problems that could deem the transplant unsuccessful.  
Review of Medical History
Pediatric dentist should gather info about the underlying disease, time of diagnosis, modalities of treatment the patient has received, and complications.
All patients with central lines must receive antibiotic coverage.
Hematologic Status
Two most important values are platelets and ANC (absolute neutrophil count)
Moderate risk of bleeding when platelets <50,000/mm3
When ANC <1000/mm3, elective dental work should be deferred because of risk of infection
Identification of Existing and Potential Sources of Infections
Medications and food may be high in carbs
Partially erupted 3rd molars can become source of infection
Pan to assess dental developmental disturbances
Dental Treatment
During first 6 months post-BMT patients have impairment of most immune functions – oral hygiene and dental rehab should be as aggressive as possible before transplant
Dental rehab should be scheduled with other medical procedures that require sedation or GA
Dental scaling and prophy should be done and carious lesions should be taken care of promptly
Pulpotomies and pulpectomies in primary teeth are not advocated because failure can lead to infection – extraction is advised.
Root tips, non-restorable teeth and permanent teeth that need RCT that can’t be completed in a single visit should be removed
Loose primary teeth should be left to exfoliate naturally
Fixed ortho appliances and space maintainers need to be removed
Oral Hygiene
Many BMT teams this brushing increases risk of bacteremia, hoever problems are more likely to aris when immunosuppressed patients are not compliant with good oral hygiene habits.
Rinses are am important part of oral hygiene protocol – keep tissue clean and moist and remove debris
It is vital to educate caretaker and child about importance of oral care in order to minimize discomfort and maximize the chances for a successful transplant.
Oral Complications during the transplant and early engraftment period
Mucositis – generalized mucosal inflammation – depends on drug dose, schedule, duration, and impairment of renal and hepatic function
- management is directed at symptomatic treatment, prevention of infection and trauma, with persistent and frequent use of strategies that enhance patient’s quality of life
Oral Bleeding – spontaneous bleeding can occur when platelets <20,000/mm3. Requires expeditious intervention b/c it may be a sign of potentially fatal hemorrhages in the CNS, respiratory tract and GI tract.
Infections – Candida albicans is the most common causative organism of oral infection in BMT patients. HSV is most common viral pathogen.
Xerostomia – optimal oral hygiene and use of frequent rinses
Acute GVHD – occurs within first 100 days post-BMT. Most common oral changes are erythema, and lichenoid changes. 

Available space for the incisors during dental development - a growth study based on physiologic age

Resident: Todd Bushman
Article title: Available space for the incisors during dental development - a growth study based on physiologic age
Authors: Moorrees, DDS; Chadha, BDS
Journal: Angle Orthod. Volume #35; Number 1; Pg 12-22
Main Purpose:  to evaluate the  available space for the incisors of the growing child by grouping children at similar stages of dental maturation with reference to tooth eruption instead of chronological age
Methods:  78 maxillary and 70 mandibular study casts were used for studying the available space in the incisor segment. Each tooth in an individual series of dental casts was classified according to one out of six stages:  1. Deciduous tooth present  2. Extracted  3. Exfoliated  4. The permanent successor emerging 5. ½ of the crown erupted 6. Fully erupted.  The difference between each stage and the previous one in the series for each child was recorded, thus events occurring during specific eruption phases could be identified.
Findings:  Emergence of mandibular central and lateral incisors resulted in 1.6mm crowding in males and 1.8mm crowding in females. In the maxilla either a small excess or a small (0.2mm) lack of space for the erupting permanent incisors was encountered. Increments in the inter-canine distance and in arch length during eruption of the lateral incisors provided enough space for the alignment of these teeth, except in the mandible where 0.2 and 0.5mm crowding was noted for males and females, respectively. No changes were noted during the emergence of the permanent canines. Pattern of change in the maxillary and mandibular dentitions of the sexes was similar. Females recover better than males from the loss of available space
Key points:
·         Available space is dependent on tooth size so observing tooth emergence and eruption should provide a realistic account of the changes in available space.   Also, combining early and late maturing children in the same chronological age has been shown to hide the actual loss of space during the incisor transition.
·         The changes in arch length and arch width are consistent with the pattern of change in available space for the incisor segment. Incisors are largely relieved when the crowns of the lateral incisors are fully erupted while if growth increments in arch size are also completed at that time.
·         A slight increase in arch width occurs in the maxillary arch when the permanent canines erupt. Increase in arch length is confined to the maxillary arch and explains why emerging incisors have nearly sufficient space for their alignment as opposed to the mandibular incisors.
·         At the end of the incisor transition the spaces between the deciduous canines and molars are closed. Mesial migration of the permanent first molars occupies most of the leeway space between the crown diameters of the deciduous posterior teeth and their permanent successors reflected in a reduced arch length.
·         The level of dental maturation gives decisive clues for diagnosis and treatment planning since it defines the timetable of individual development. Chronologically based methods often mask the characteristic features that distinguish one child from the next. The sources of variance for available space of the incisors are tooth size and growth of the alveolar processes.
Assessment:  Interesting article that helps us better understand our patient’s needs

Wednesday, May 1, 2013

Trico-dento-osseous Syndrome

Trico-dento-osseous Syndrome
Resident: Mackenzie Craik

Definition: Tricho-dento-osseous (TDO) syndrome is an autosomal dominant genetic disorder that belongs to the group of diseases known as ectodermal dysplasias. It derives its name from the three primarily affected tissues including hair, teeth and bone.

Etiology: It is caused by a DLX3 gene mutation. Research suggests that Amelogenesis imperfecta of the hypomaturation-hypoplasia type with taurodontism and TDO are two genetically distinct conditions.

Clinical Features: TDO syndrome is characterized by kinky or curly hair; poorly developed tooth enamel; and unusual thickness and/or denseness (sclerosis) of the top portion of the skull (calvaria) and/or the long bones. In some cases, affected individuals also exhibit abnormally thin, brittle nails or premature fusion of the fibrous joints between certain bones in the skull (craniosynostosis), causing dolicocephaly.
Kinky, course and/or curly hair is present at birth in 80% of people with TDO. Only 46% of the individuals with TDO and kinky, course and/or curly hair at birth retain this phenotype after infancy. There is an increased cranial thickness. The loss of visible mastoid pneumatization is the most common osseous feature seen in affected individuals (82%) and is relatively uncommon in unaffected people (8%).

Oral Manifestations: While all individuals with TDO appear to have enamel hypoplasia and taurodontism, the expression of these traits is highly variable. The teeth appear discolored in 76% of the affected individuals while the remaining affected individuals have teeth of normal color. Enamel alteration in people with TDO ranges from being extremely thin and/or rough and pitted to being of normal color and only slightly decreased thickness.

Treatment: Symptomatic.

Dental Considerations: Treatment depends on severity of defects and esthetic demands of patient and may include full coverage restorations.

Lesch-Nyhan Syndrome

Lesch-Nyhan Syndrome
Resident: Mackenzie Craik

Definition: Lesch-Nyhan syndrome is an inheritable disorder that affects how the body builds and breaks down purines.

Etiology: inherited as an X-linked trait. It mostly occurs in boys. Persons with this syndrome are missing or are severely lacking an enzyme called hypoxanthine guanine phosphoribosyltransferase 1 (HGP). The body needs this enzyme to recycle purines. Without it, abnormally high levels of uric acid build up in the body.

Frequency: about 1 in 380,000 people.

Clinical Features: The excess uric acid levels cause children to develop gout-like swelling in some of their joints. In some cases, kidney and bladder stones develop because of the high uric acid levels. Males with Lesch-Nyhan have delayed motor development followed by bizarre, sinuous movements and increased deep tendon reflexes. A striking feature of Lesch-Nyhan syndrome is self-destructive behavior characterized by chewing off fingertips and lips, if not restrained that begins in the second year of life. It is unknown how the enzyme deficiency causes these problems.

Oral Manifestations: The most typical feature results in partial or total destruction of perioral tissues.

Treatment: Treatment for LNS is symptomatic. Gout can be treated with allopurinol to control excessive amounts of uric acid. Kidney stones may be treated with lithotripsy, a technique for breaking up kidney stones using shock waves or laser beams. There is no standard treatment for the neurological symptoms of LNS. Some may be relieved with the drugs carbidopa/levodopa (used to treat Parkinson's disease), diazepam, phenobarbital, or haloperidol (antipsychotic).

Dental Considerations: A soft mouthguard fabricated to prevent the destruction of perioral soft tissues and combined psychiatric pharmacologic therapy proved to have satisfactory results. In extremem cases, teeth may need to be extracted.

Prognosis: The outcome is likely to be poor. Persons with this syndrome usually require assistance walking and sitting and generally need a wheelchair to get around. Death is usually due to renal failure in the first or second decade of life.



Overview: A rare and sometimes fatal metabolic bone disease.


- Caused by 1 of 200 genetic mutations in gene that encodes TNSALP enzyme

- Autosomal recessive disorder

Diagnosis: The pathognomonic symptom is subnormal serum activity of alkaline phosphatase (ALP).  IN infants x-ray can provide diagnostic features including hypomineralization, rachitic changes, incomplete vertebrate ossification and occasionally, lateral bony spurs on the ulnae and fibulae

Oral manifestations:

- Early loss of deciduous dentition with root intact

- Little cementum produced

Clinical manifestations:

- Symptoms can range from profound skeletal hypomineralization and respiratory compromise to progressive osteomalacia

- Lack of serum alkaline phosphatase

- urinary phosphoethanolamine

In epidermolysis bullosa

- Fibrous acellular cementum

- Excess cellular cementum

In Cleidocranial dysplasia

- deficient cellular cementum

Special dental considerations/needs:

- Early loss of deciduous dentition with root intact


Current management consists of palliating symptoms, maintaining calcium balance and applying physical, occupational, dental and orthopedic interventions as necessary.


AAPD Handbook