Wednesday, June 19, 2013

Managing patients who have seizure disorders: Dental and medical issues

Resident: Matthew Freitas
Author: Weddell JA
Journal: JADA 1995 Dec;126(12):1641-7

Background:
-0.5% of the US have a seizure disorder
-Prevalence highest between 2-5yo and at puberty
-Seizures are classified based on whether the abnormal electrical activity begins in a localized area (partial) or throughout the brain (generalized).

Medical Considerations:
-Obtain a thorough medical history
-Most patients with a seizure disorder are well maintained and are able to receive routine dental care
-It is important to know the history of the seizure disorder (frequency, triggers, symptoms, medications)
-Most important to maintain adequate airway
-Place a rolled towel under the patients neck
-Monitor vitals
-Contact emergency medical care

Dental Considerations:
-Fixed prosthesis and better than removable
-Most common complication is drug induced gingival hyperplasia; best to keep patients on a 3M recall

Conclusion:
-The information you obtain will make you and your staff more comfortable to manage the seizure, and possibly prevent one from occurring and provide better service to the patient over-all

Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients

Todd Bushman
Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients.
by Francisco J Ramos-Gomez, Catherine Flaitz, Peter Catapano
Journal of Clinical Pediatric Dentistry
The criteria for diagnosis of HIV-related oral lesions in adults are well established, but corresponding criteria in the pediatric population are not as well defined. The Collaborative Workgroup on the Oral Manifestations of Pediatric HIV infection reached a consensus, based upon available data, as to the presumptive and definitive criteria to diagnose the oral manifestations of HIV infection in children. Presumptive criteria refer to the clinical features of the lesions, including signs and symptoms, whereas definitive criteria require specific laboratory tests. In general, it is recommended that definitive criteria be established whenever possible. Orofacial manifestations have been divided into three groups:
1) those commonly associated with pediatric HIV infection;
2) those less commonly associated with pediatric HIV infection; and
3) those strongly associated with HIV infection but rare in children.
Orofacial lesions commonly associated with pediatric HIV infection include
candidiasis - antifungal treatments.  most common oral lesion in children
herpes simplex infection - viral infection that clears up quickly in healthy children.  If they have HIV often times this leads to hospitalization.
linear gingival erythema - most common form of HIV associated periodontal disease
parotid enlargement - 10-30% of HIV patients get parotid swelling.  If this sign is present the child should get tested for HIV
recurrent aphthous stomatitis - although apthus ulcers may resemble some forms of candidiasis, they will respond to steriod treatment, unlike fungal infections.
In contrast, orofacial lesions strongly associated with HIV infection but rare in children include
Kaposi's sarcoma - 
non-Hodgkin's lymphoma, and
oral hairy leukoplakia.
In the last few years, the implementation of new and different drug protocols has allowed HIV infected children to be maintained alive and asymptomatic.  Orofacial manifestations should be considered the earliest clinical sign of HIV infection and a good indicator of disease progression in children.  Since the mouth is easily examined, certain oral signs may be used to increase early detection and provide a basis for more aggressive and appropriate treatment of HIV infection, improving the overall health outcome of the vulnerable population.
Assessment: Great article that gives us a heads up on what we need to look for to help identify and treat patients with HIV.

Biological mechanisms of early childhood caries

Kyung-Hong Cal Kim

Biological mechanisms of early childhood caries

Authors: Seow WK

Community Dentistry and Oral Epidemiology1998

Purpose:
To review the biological mechanisms involved in ECC and to screen for factors which might provide clues to its complex etiology

Key Points
Dental plaque
-First stage in plaque formation involves the deposition on the tooth surface of an acquired pellicle which plays significant roles in microbial colonization and dental caries
-There is a progressive shift from mainly aerobic and facultatively anaerobic species in the early stages to more facultatively anaerobic and anaerobic species after 9 days.

Acid production in dental plaque
-When fermentable carbohydrates are present, lactate is mainly produced, which coincides with a pH drop in plaque

Virulence of Mutans Streptococci
-MS produce large amounts of acid, particularly lactic acid, which are potent in driving tooth demineralization
-The aciduricity or acid tolerance of the bacteria is extremely high, thus allowing colonization and persistence under cariogenic conditions

Colonization of MS in dental plaque
-In the absence of sucrose, other bacteria such as S. sanguis have a higher affinity for pellicle-coated teeth than MS
-In the absence of exogenous carbohydrates, MS contain low levels of intracellular polysaccharide, and there is little substrate for substantial bacterial growth and accumulation
-In the presence of sucrose, MS irreversibly adhere to the pellicle through the synthesis of glucans mediated by glucosyltransferases produced by the bacteria

Establishment of MS in infants
-Most studies including predentate children show that MS are usually not cultured from the oral cavity prior to the eruption of teeth
-Infection rate of MS increases with age, as well as the number of teeth present in the infants’ mouth

Transmission of MS
-A minimum infective dose of MS is necessary for implantation, which is enhanced by repeated inoculation

Immunological factors
-Secretory IgA may inhibit bacterial adherence and/or agglutination, as well as neutralization of bacterial enzymes, but there is little evidence that naturally occuring IgA antibodies protect against dental caries
-Although controlled animal studies have reported less dental caries in those which suckled on breast milk containing antibodies to MS, the protection by passively transferred IgA through breast-feeding has not been verified in humans

Tooth maturation and defects
-Period immediately after eruption and prior to final maturation is when the tooth is most susceptible to caries

Association of enamel hypoplasia with dental caries
-Surface irregularities such as pits and grooves predispose to plaque retention, increased MS colonization, and possibly, decreased clearance of carbohydrates. Alteration or loss of the enamel surface due to enamel hypoplasia predispose a tooth to increased caries risk

General cariogenicity of sugars
-Sucrose is the only substrate used for bacterial generation of plaque dextrans which are essential for bacterial adherence
-Sucrose, glucose and fructose found in fruit juices and vitamin C drinks as well as in solids are probably the main sugars associated with infant caries

Frequency of consumption
-Increased frequency of eating sucrose increases the acidity of plaque, and enhances the establishment and dominance of the aciduric MS

Oral clearance of carbohydrates
-The low salivary flow during sleep decreases oral clearance of the sugars and increases the length of contact time between plaque and substrates, thus increasing the cariogenicity of the substrate significantly
-Clearance of glucose is slowest on the labial surfaces of the maxillary incisors and the buccal surfaces of the mandibular molars

Cariogenicity of foods
-There is no evidence to suggest that bovine milk is cariogenic.
-Human breast milk has a lower mineral content, higher concentration of lactose, and less protein, but these differences are insignificant in terms of cariogenicity

Fluorides
-Even at very low concentrations, fluoride can affect the demineralizing process in a carious lesion by decreasing the rate of subsurface dissolution and enhancing the deposition of fluoridated apatite in the surface zone. 


Assessment of the Article
It was a very tough read that was 20 pages long, but it was an informative article that answered many questions on why we ask certain questions during our caries risk assessment.

Risk factors for drug-induced gingival overgrowth


Resident: Derek Nobrega
Title: Risk factors for drug-induced gingival overgrowth
Authors: RA Seymour, JS Ellis, JM Thomason
Journal: Journal of Clinical Periodontology 2000, 27: 217-223

Main Purpose:
To identify and quantify the various risk factors associated with both the development and expression of the drug-induced gingival changes.

Methods:
The following risk factors were evaluated: age and other demographic factors, drug variables, concomitant medication, periodontal variables, and genetic factors.

Results:
- Age has been reported as risk factor for phenytoin (most severe in teenage years) and cyclosporine (higher in children than adults), but not for calcium channel blockers (these drugs usually confined to middle age and older adults)
- Gender and race are not important risk factors for gingival hyperplasia.
- Drug dosage is a poor predictor of gingival changes, but drug concentration in saliva is a positive predictor
- The combination of some drugs produces more gingival overgrowth than if either drug was used singularly
- Plaque scores and gingival inflammation appear to exacerbate the expression of drug-induced gingival overgrowth

Assessment:
Some of our patients may be taking drugs that are linked to gingival overgrowth. It is important that we know these drugs, and can educate the patients and let them know what may lower their risk of gingival overgrowth, ie meticulous oral hygiene. 

Tuesday, June 18, 2013

Recurrent Aphtous Stomatitis

Oral Surgery, Oral Medicine, Oral Pathology
Volume 81 No. 2
February 1996
Jonathan A. Ship

Purpose: Review of of aphtous stomatitis in its various forms

Key Points:
  • Primarily present in three forms:
  • Minor: round, well circumscribed ulcers that heal in 10-14 days without scarring
  • Major: ulcers greater than 5 mm that last for 6 weeks or longer and can leave scarring
  • Herpetiform: Minor lesions which form in clusters
  • Aphtous ulcers are very common and occur in 25%-60% the population
  • Ulcers generally first appear at 10-19 years of age and can recur throughout life
  • Most common site is on nonkeratinized oral mucosa
  • Many factors are associated with aphtous stomatitis however no cause is known
  • Factors associated include denture wear, cytomegalovirus infection, varicella-zoster, HIV, Bechet's, Chron's disease, B vitamin deficiency, and family history.
  • Treatment is generally paliative with topical glucocorticoids and analgesics however CO2 lasers have shown to be effective

Review of Monitors and Monitoring During Sedation with Emphasis on Clinical Applications

Resident: Elliot Chiu
Title: Review of Monitors and Monitoring During Sedation with Emphasis on Clinical Applications
Journal: Pediatric Dentistry 1995
Author: Stephen Wilson

Pulse Oximetry
-Continually measures indirectly O2 saturation and heart rate
-Sensor contains 2 elements: one emits light in red and infrared wavelengths and the other detects light transmission through tissue
-Oxygenated hemoglobin absorbs more red while deoxygenated hemoglobin absorbs more infrared wavelengths
-Signal errors may be caused by: crying, cold limbs, nail polishes, profound tissue pigmentation in some blacks

Blood Pressure Cuffs
-A combative or uncooperative child would be expected to have an elevated BP, which tends to decrease to normal values as the child becomes sedated
-In dosages designed to produce conscious sedation, most sedative agents do not cause significant clinical changes in BP

Capnography
-Measure expired CO2 concentrations with infrared absorption technology
-Normal CO2 concentrations in children range from 33-40mm Hg
-Most have an alarm to indicate an obstruction

Precordial Stethoscopes
-Can obtain heart, respiratory, GI, and joint sounds
-Placement of the stethoscope can cause breathing sounds or cardiac sounds to be predominant
-During sedations, airway sounds are more important

Monday, June 17, 2013

Temporomandibular Disorders: A Review of Current Understanding

Resident: Jeff Higbee
Article: Temporomandibular Disorders: A Review of Current Understanding (1999)
Author: Goldstein, BH

Overview: Review of evidence regarding the understanding, evaluation, management and tx of TMD to provide a broad perspective to an important and controversial subject.

Definition and Classification of TMD:
- A nonspecific dx that represents a group of often painful and/or dysfunctional conditions involving the muscles of mastication and the tMJ.
- Symptoms and disorders of the muscles of mastication, TJM, nervous system and behavior.
- Most common type (90-95%) is multiple musculoskeletal facial pain and a variety of jaw dysfunction and without any identifiable structural cause.
- Correct dx of TMD requires a subset of specific diagnoses which must include jaw muscles, bone and cartilage, soft tissue joint, jaw and joint function, analysis of pain disorder and patient behavior.

Causation:
- Range from trauma to immune mediated systemic disease to neoplastic, neurobiologic and growth disturbances.
- Chronic parafunctional habits
- Malocclusion in NOT established as an important factor in TMD.
- No evidence that common or routine dental or medical tx causes TMD.
- Orthognathic surgery, orthodontics, prostho, and mandibular fracture repair can worsen preexisting TMD.
- TMD may be a manifestation of chronic pain.
- FM (fibromyalgia) and TMD have symptoms but are considered separate.
- No anatomic risk factors have been identified for TMD development.

Diagnosis of TMD:
- Pt. history
- Physical evaluation
- Behavior and psychologic assessment
- Panoramic and study models are helpful

Natural Hx of TMD:
- 33% of humans have TMJ click without pain or dysfunction
- Woman>men
- Altered condylar neck morphology with TMJ and disk displacement appear to be strongly related but may occur independently
- Morphologic changes do no equal poor prognosis and may be considered adaptation
- Masticatory muscle pain TMD does not progress in severity with age

Management:
- Reversible therapy that facilitates natural musculoskeletal healing
- Avoid irreversible tx
- Current standard of care: multidisciplinary tx
- Common dental tx is splint therapy
- Occlusal adjustments, orthodontics, restorations, TMJ and/or joint surgery that change bite of teeth is inappropriate

Wednesday, June 12, 2013

Overweight and Dental Caries Among US Children

Resident: Matthew Freitas
Article Title: Exploring the Association Between Overweight and Dental Caries Among US Children
Authors: Macek, et al.
Journal: Pediatric Dentistry 28:4 2006

Main Purpose: Examine relationship between age-specific BMI and dental caries among US kids

Background: An increasing number of US children and teenagers are overweight. Minority and low socioeconomic status-youth are at greater risk. Overweight kids often consume foods high in fats and refined carbs. The authors hypothesized that overweight might be a marker for dental caries in kids due to relationship between refined carbs and caries. 

Methods: Data from the NHANES survey (1999-2002) were used.  Outcome variables included 1) measures of dental caries prevalence and 2) caries severity in both dentitions, both of which were represented by dft and DMFT.

Results: Controlling for confounders,
1.  they found no statistically significant association between BMI for age and caries prevalence in either dentition.
2. No significant association with caries severity in the primary dentition.
3.  Overweight kids with past caries experience in permanent dentition actually had lower DMFT than their normal-weight peers!?

Discussion:  Interesting article. I expected an association between obesity and caries.

Dental disease prevalence among methamphetamine and heroin users in an urban setting

Resident Name: Todd Bushman

Article Info:  Dental disease prevalence among methamphetamine and heroin users in an urban setting

Main Purpose: To follow young drug users and learn about the affects on dentition.

Methods:  This pilot project was a cross-sectional study of an ongoing cohort of young adult injection-drug users in San Francisco. Participants completed an oral health questionnaire administered by a research assistant, and dentists performed clinical examinations to record the participants’ data in terms of scores on the decayed-missingfilled surfaces (DMFS) index, presence of residual roots, scores on an oral hygiene index and whether any salivary hypofunction was observed.

Key Points: The prevalence of dental disease among 58 young adult IDUs was strikingly high compared with that in the U.S. general population; however, the authors found no difference in the level of dental disease
between users of methamphetamine and users of heroin. The mean DMFS score and number of decayed surfaces exceeded 28 in both groups.
Lessons learned from this exploratory study suggest that a large sample size, a more elaborate
sampling strategy and a study design such as cohort-control, in which participants are recruited according to their exposure or risk factor, may be needed in future research to explore the association between any specific drug used and dental disease. This may require consideration of patients living in rural settings,
where methamphetamine use may be more prevalent or may be used exclusively. Meanwhile,
given the high level of dental disease observed in this population of IDUs, one next step may be to explore the feasibility and effectiveness of low-intensity preventive measures for this population (for example, distribution of chlorhexidine rinses or xylitol gum or application of fluoride varnishes). Furthermore, providing oral health education and low-intensity intervention at sites where drug users typically receive public health services and enlisting the help of outreach workers in these settings may
help encourage disenfranchised drug users to accept selected strategies to prevent dental
disease.
Although the authors detected no difference in dental disease between methamphetamine and heroin users, they found a high prevalence of caries and caries-associated behaviors in the sample of young adult IDUs.

Assessment of Article:  The article was fairly weak and needed a larger sample size.  The authors talked about this in the article as well. But it is interesting.  We don’t see too many drug users but we need to be able to recognize it when we do.

Association between Childhood Obesity and Dental Caries

Kyung-Hong Cal Kim

Association between Childhood Obesity and Dental Caries

Authors: Werner SL, Phillips C, Koroluk LD

Pediatric Dentistry Jan/Feb 12

Purpose:
To investigate dental caries and body mass index in pediatric dental patients

Background information:
-The 2003-2006 NHANES survey found that 17% of 6- to 11-year-olds were obese vs only 7% from 1976 to 1980
-CDC defines overweight children as having a BMI percentile at or above the 85th percentile and below the 95th percentile
-CDC defines obese children as having a BMI percentile at or above the 95th percentile
-People today are ingesting more calories than they are expending, resulting in energy stored as fat
-Environmental causes of obesity include the increased accessibility of high fat foods, increased consumption of sodas, decrease in exercise, increase in sedentary work situations, and increased technology-driven playtime
-Overweight children are at a greater risk for becoming overweight or obese adults who develop CVD, DMII, HTN, orthopedic problems, OSA, and asthma

Methods:
-6- to 9-year-olds seen for a new patient exam in the UG pedo clinic at UNC after Jan 2005 who had a subsequent recall exam before Sep 2008 (mixed dentition and prepubertal)
-Free of significant systemic disorders
-Retrospective study of electronic charts that recorded the number of decayed permanent and primary teeth, height, weight, plaque score, gingival score, Medicaid status and zip codes at the initial visit
-3 categories: underweight/healthy, overweight, and obese

Results/Discussion:
-Total of 230 subjects, 114 females and 116 males met inclusion criteria
-Initially, 12% of subjects had permanent tooth caries and 46% had primary tooth caries
-13% were obese, 15% were overweight, and 72% were underweight/healthy
-Smaller proportion of obese and overweight children presented with primary tooth caries than underweight/healthy children (more fatty foods, less sugary foods for overweight subjects? Being overweight is protective against dental caries?)
-Presence of new carious lesions at recall exams in both permanent and primary teeth was not significantly different between BMI groups
-SES and Medicaid status were not related to the presence of caries in permanent or primary teeth, or to BMI categories
-There was a marginally significant difference in the proportion of high and low plaque scores between BMI categories, with the overweight category having a lower proportion of subjects with a plaque score greater than 10 than underweight/healthy or obese subjects

Assessment of the article:
Interesting attempt to see the correlation between obesity and dental caries in children. Unfortunately, this study appears to have created more question marks than provided answers. I assumed that there would be a clear positive association between obesity and dental caries prior to reading this article, only to be surprised by learning that smaller proportion of overweight children were suffering from dental caries than those who are underweight or healthy. I am curious to find out what is the reason behind that phenomenon.

AAPD Handbook: Ch 25 New Morbidities

Resident: Elliot Chiu
Pregnancy:
-5-8% teenage population
-"Term" labor: 36-42 weeks. Low birth weight: <2500g.
-Pregnancy itself is no reason to postpone routine and necessary dental care. Emergency/needed tx ideal between 14-20th week as the patient may have morning sickness in the first trimester and physical discomfort in third.
-FDA category B drugs may be used during pregnancy: Penicillin, amoxicillin, clindamycin, acetaminophen, ibuprofen and 2% lido w/ 1:100,000 epi
Obesity & Eating Disorders:
-Obesity: BMI > 95th percentile. Overweight: BMI >85th percentile.
-Eating disorders: ~90% female, highest mortality rate of any mental illness.
-Anorexia nervosa characterized by BMI <5th percentile.
-Bulimia patients may present with dental erosion and soft palate injury from induced vomiting.
Substance Abuse:
-Overindulgence in and dependence on a stimulant, depressant, chemical substance, herb or fungus leading to effects that are detrimental to an individual’s health or welfare of others.
-Approximately 50% of US high school students will experiment with at least one illicit drug before graduating.
-Using alcohol and tobacco at a young age increases risk of using other drugs later.
Tobacco:
-Almost 25% children are current smokers by the time they leave high school. 90% of adult smokers began before the age of 18.
-Leukoplakia, which can lead to oral cancer, occurs in more than half of all spit tobacco users in the first 3 years of use.
-5As Intervention to treat tobacco dependence: Anticipate, Ask, Advise, Assess, Arrange

Tuesday, June 11, 2013

Prenatal dental care: A review


Resident: Derek Nobrega
Title: Prenatal dental care: A review
Authors: Homa Amini, DD S, MPH, MS n  Paul S. Casamassimo, DD S, MS
Journal: General Dentistry. May/June 2010. 176-180.

Main Purpose: To discuss common dental findings and treatment considerations during pregnancy.

Overview: Good oral health during pregnancy is necessary for the health of both the mother and the baby. Dental care during pregnancy is safe, effective, and recommended, yet many dental professionals delay treatment due to concerns for fetal safety.

Key Facts:
-  The Surgeon General’s 2000 report on oral health emphasized dental treatment during pregnancy as a way to improve maternal and infant health; however, few women visit a dentist during pregnancy.
-  Untreated dental disease can lead to pain, infections, and unnecessary exposure to medications, any of which might be harmful to the developing fetus.
-  Poor oral health has also been linked to adverse pregnancy outcomes. Some studies suggest an association between maternal periodontal disease and preterm birth; in addition, evidence indicates that a child can acquire oral biofilm from the mother and/or caretaker, and poor maternal oral health may be a potential risk factor for ECC.
Common Oral Findings:
-  The most common oral disease during pregnancy is gingivitis, which has been reported in 30–100% of pregnancies.
-  Tooth mobility may be a sign of periodontal disease.  However, increased levels of progesterone and estrogen may affect the periodontium, and mobility may be observed in the absence of periodontal disease; in such cases, the condition will resolve after delivery.
-  Pyogenic granuloma (also known as pregnancy tumor) is a benign, painless, vascular lesion that occurs in up to 5% of pregnancies associated with hormonal fluctuations in combination with local irritants and bacteria.
Treatment Considerations:
-  Dental treatment can be delivered safely at any time during the pregnancy with no more fetal or maternal risk when compared to the risk of not providing care.
-  Dental radiographs are safe at any time during pregnancy as long as the dental team follows good radiologic practices and ALARA principles.
-  The second trimester is an ideal time for routine general dentistry, as the risk of spontaneous abortion is lower and organogenesis is complete.
-  Dental appointments should be kept short, allowing for frequent changes in position and making sure to keep the head above the feet.
-  Elective dental procedures can be deferred until after delivery.
-  When treating pregnant women, dentists must understand which drugs can be prescribed and administered.
- Acetaminophen is safe. Ibuprofen should be avoided during 1st and 3rd trimesters, and only used for 24-72 hours.
- Doxycycline and tetracycline are not safe. Penicillin and clindamycin are safe.
-  Lidocaine and Prilocaine are safe
- Barbiturates and benzodiazepines are not safe. Nitrous oxide is not rated.

Assessment:
As we are in practice, it is likely we will treat pregnant patients and also will see our patients’ mothers who may be pregnant with subsequent children. We should encourage pregnant women to visit the dentist during their pregnancy and let them know that it is safe, as it is directly related to the child’s health. 

Oral Healt Policies on Tobacco Use and Oral Piercings

Tobacco:
  • Tobacco is a risk factor for 6 of the 8 major leading causes of death in the US
  • Smoking is the leading cause of preventable death in the US
  • 440,000 people die  from smoking and 50,000 die from secondhand smoke
  • Thirdhand smoke is now being studied and appears to disproportionately affect children
  • $193 billion is spent annually on lost productivity and health care costs from smoking; $10 billion is spent on second hand smoke
  • The AAPD opposes tobacco in all forms and supports clean air laws indoors and outdoor places
  • AAPD encourages members to make offices smoke free and discourages members and staff from smoking
Oral Piercings:
  • Piercings have been associated with infection, fractured teeth, perio disease, and nerve damage
  • Life-threatening sequalae include bleeding, edema, and airway obstruction
  • Piercing parlors are unregulated and have been cited by NIH as transmitters of infectious disease (Hepatitis, tetanus, and TB)
  • AAPD opposes intraoral and perioral piercings. 

Pinkham Chapter 11: Dental Public Health Issues in Pediatric Dentistry

Resident: Mackenzie Craik

Publication: Pinkham Textbook; Pediatric Dentistry: Infancy through Adolescence, 3rd Edition.

Chapter: 11: Dental Public Health Issues in Pediatric Dentistry

Author: M.J. Kanellis


Definition of Dental Public Health:

  • Defined as "the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts".


Role of the Individual Practitioner:

  • The challenge for all dentists, is to look beyond the individual dental office and make a broad assessment of their community's needs while assessing their own role in enhancing the oral health of the entire community.  
  • One important issue practitioners often find themselves involved with is enhancing access to dental care for members of their communities.  
Access to Care:
  • Millions of children each year have difficulty  receiving the care they need.  These children are most often from low-income or minority families and unfortunately these groups tend to experience more oral disease than other children.
  • Some of the factors that can limit access to dental care for these children are (1) lack of finances (insurance), (2) lack of transportation (3) lack of perceived need for care.
Barriers to Care for Infants and Toddlers from Low-Income Families:
  • Dental care for infants and toddlers from low-income familes presents a dilemma for several reasons.  These children often (1) lack financial access to care, (2) have care givers who fail to recognize the importance of early dental visits, (3) have difficulty finding a dentist who will accept Medicaid, and (4) have difficulty finding a dentist who will see children under the age of 3 years old.
School-Based Dental Care:
  • Examples of services that can be provided in a school-based setting include oral health education, fluoride mouth-rinsing, sealant placement, oral health screenings and referrals, and comprehensive restorative care.
  • School-based dental care can provide a means for increasing both access and use of dental services for children who do not or cannot receive care in the private sector.
Assessment: A good reminder of some of the issues involved with participating in Dental Public Health.  Even though we do this every day at St. Joe's, it can be good to remember some of the struggles that many of our patients deal with.

Monday, June 10, 2013

Barriers to Utilization of Dental Services During Pregnancy: A Qualitative Analysis

Resident: Jeff Higbee
Article: Barriers to Utilization of Dental Services During Pregnancy: A Qualitative Analysis
Journal: Journal of Dentistry for Children-76:1, 2009
Authors: Mai Le, DDS, MSD; et al

Purpose:
- Dental services during pregnancy can improve maternal oral health, reduce mother-child transmission of cariogenic bacteria, and create opportunities for anticipatory guidance.
- The purpose of this study was to understand why low-income women did or did not utilize dental services in a pilot program to promote dental visits during pregnancy.

Methods:
- Women were selected randomly.
- 51 women were asked to participate in semi-structured telephone interviews regarding utilization of dental services during pregnancy.
- Transcripts were content analyzed using a mixed method qualitative approach.

Results/Key Points:
- Most women overcame stress or dentally related barriers to obtain care.
- Stressors included poor domestic relationships, personal finances, and employment.
- Dentally related factors included perception of dental experience, attitude toward dental providers, importance/valuing of oral health, perceived ability to pay for care, time constraints, and dental providers’ and office staff attitudes toward clients.

Conclusion/Assessment:

Pregnancy stressors and dentally related issues were identified as barriers to utilizing dental services.  Because we may treat teen patients who are pregnant, it is important to understand the barriers to treatment and other factors that may affect appropriate dental care during pregnancy.   

Wednesday, June 5, 2013

Guideline on Oral and Dental Aspects of Child Abuse and Neglect

Resident: Matthew Freitas
Journal: Pediatric Dentistry, Volume 31, Number 6, September/October 2009 , pp. 86-89(4)
Clinical Guidelines Manual

Purpose:
To review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions.

Physical & Sexual Abuse:
-Physical: craniofacial, head, face and neck injuries account for more than half of the cases of child abuse. 
-Often the oral cavity is a central focus of physical abuse by the abuser (lip injuries).
-Sexual: indicated with oral and perioral gonorrhea in prepubertal children. As well as unexplained palatal injury.
-Lab testing: tissue samples can be taken by swabbing buccal mucosa with a sterile cotton-tipped applicator. However, hospitals typically have specialized personnel in cases when physical and sexual abuse is suspected.

Bite Marks:
-Suspected bite marks can be identified with ecchymoses, abrasions, or lacerations of the skin in an ovoid pattern.
-Human bites tend to compress skin rather than tear skin (animal bite).
-A photograph should be taken and one may also want to measure the lesion and take an impression.
-The materials can be sent to a certified forensic lab.

Dental Neglect:
-Willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection. 
-Neglect can adversely affect learning, communication, nutrition and growth/development.
-Neglect should be considered after the dentist had informed the parent of their child's needs, and the parent fails to follow through with their necessary care.

Conclusions:
-Physicians are encouraged to identify such dentists in their communities as consultants for a multidisciplinary child abuse and neglect team approach.
-A team effort approach will help to identify, treat and prevent abuse and neglect.

Human biting of children and oral manifestations of abuse: A case report and literature review

Kyung-Hong Cal Kim

Human biting of children and oral manifestations of abuse: A case report and literature review

Authors: Lee LY, Ilan J, Thomas Mulvey

Journal of Dentistry for Children Jan-Apr 2002

Background Information
-Bite indicates a purposeful contact by another individual and is evidence of intentional abuse
-In abused infants and young children, bite marks tend to be found on the cheeks, the back, side, arms, or buttocks and are usually rendered as a result of uncontrollable anger
-In older children and adolescents, bite marks are of abuse tend to reflect assault or sexual abuse, often occurring on the neck, breasts, stomach, and genitals
-Intercanine distance, if marks from canines are visible, will be greater than 3 cm in permanent dentition
-Appearance of bite will change over time, and it will be especially rapid in children where the healing process is faster
-Black and white or color photographs (taken every 24 hours for 7 days), collection of saliva washings (specific A,B,O antigens found in saliva aids the investigation of the suspected perpetrator), and impressions (at least 0.5 in ch margin beyond the lesion) for record
-Animal bite marks usually result in deep tissue penetration with accompanying tearing and lacerations; human bite marks tend to leave more superficial lesions, which include bruising or abrasions

Case
-10-month-old female admitted to Children’s Hospital of New York for seizures and respiratory distress
-Hx of multiple fractures
-Multiple skin lesions at various stages of healing
-Chest film indicated multiple healing rib fractures, resulting in respiratory distress
-Laceration of the tongue, healing by secondary intention
-Self-infliction ruled out, as its concave surface of the arch was pointing labially
-(+) for HSV 2 from an intraoral lesion
-(+) for Serratia marcescens from the tongue laceration
-(+) for Candida from ear lesions

Assessment
Very descriptive article co-written by our very own Dr. Tom Mulvey. This case shows how a child that gets admitted to ED for evaluation of different things can take such a drastic turn by further evaluating the child. It was interesting that ED requested consultation by pediatric dental department. I would be curious to find out the outcome of this case, and it would lead to an interesting conversation with Dr. Mulvey next time I see him around the clinic. 


ps: I tried different things to add the picture from the article of the tongue laceration as it is worth a look, but I wasn't able to do so. I'm sorry.

The rate of child abuse and neglect cases per population totals decreased since the mid 1990s ... BUT!

Resident: Jeff Higbee
Article: The rate of child abuse and neglect cases per population totals decreased since the mid 1990s ... BUT!
Journal: Journal of Dentistry for Children Sep.-Dec. 2002
Authors: Waldman, H. DDS, Pearlman, S. DDS

Categories of maltreatment
- Neglect
- Physical Abuse
- Sexual Abuse
- Medical Neglect
- Psychological Maltreatment

In the year 2000
- Almost two-thirds of child victims (63percent) suffered neglect (including medical neglect).
- 19 percent were physically abused.
- 10percent were sexually abused.
- 8 percent were psychologically maltreated.

Victimization rates decline as age increases, younger children are at greater risk for maltreatment.
- The rate of victimization for children in the age group of birth to 3 years old was 15.7 victims per one thousand children of the same age.
- The rate of victimization for children ages 16 and 17 was 5.7 victims per one thousand children of the same age in the population.

The rate for maltreatment is similar among males and females except for sexual abuse where females are 4 times more likely to be abused.
- More than half of all victims were white (51percent).
- A quarter (25 percent) was black.
- 15 percent were Hispanic.
- American Indian/ Alaska Native accounted for 2 percent of victims.
- Asian/Pacific Islanders accounted or 1 percent of victims.

Predators - Most states describe the perpetrators of child abuse or neglect to be parents or other caretakers, such as relative, babysitters, and foster parents.
- A parent or parents abused more than 4-out-of-5 victims (84 percent).
- Mothers acting alone were responsible for 47 percent of neglected victims and 32 percent of physical abuse victims
- Nonrelatives were responsible for 29 percent of sexual abuse victims. Fathers acting alone were responsible for 22 percent of sexual abuse victims; other relatives were responsible for 19 percent?

Fatalities - Approximately 1,200 children died of abuse or neglect in 2000.  The rate of fatalities from abuse or neglect in 2000 was 1.71 children per 100,000 children in the population.

Tuesday, June 4, 2013

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries

Diagnosing abuse: a systematic review of torn frenum and other intra-oral injuries
Sabine Maguire
Archives of Disease of Childhood 2007

Purpose: Evaluate if a torn labial frenum can be used as an indicator of abuse in children

Methods: Studies from 1950 to 2006 were reviewed and compiled.  19 studies ended up being included which represented 591 children.

Key points:
  • In the past, a torn frenum was considered by pediatricians to pathognonomic for abuse however it is considered relatively minor by dentists as it generally heals without complication and without intervention
  • Injuries to face and teeth are extremely common in children
  • The inclusion of the torn frenum as indicator of abuse was in 1966 and was done by noting that in more than half of fatally abused children there was lacerations of the oral mucosa.  There only two description of causality of the injuries and both were direct blows to the face.  Two others were complications of intubation in fatally abused children
  • None of the studies reviewed had injuries reviewed by a dentist
  • There are no studies documenting the frequency of torn frenums in the general population therefore it is impossible to use it as indicator of abuse
  • The studies used to justify this classification were almost all descriptions of confirmed abuse rather than suspected abuse that was later confirmed
  • A torn frenum should not be used by itself as an indicator of abuse.
Assesment: Nice info about something I think most of us already know because we see traumatically torn frenums regularly.  I do think it is important to make sure that the story of how the frenum was torn checks out to make sure the injury was not a result of abuse. 

Knowledge and Professional Experiences Concerning Child Abuse: An Analysis of Provider and Student Responses

Resident: Elliot Chiu
Title: Knowledge and Professional Experiences Concerning Child Abuse: An Analysis of Provider and Student Responses
Journal: Pediatric Dentistry 2006

Main Purpose:
To explore dentist, hygienist, and student knowledge about their professional responsibilities concerning suspected child abuse.

Methods:
A survey was collected from 220 general dentists, 158 hygienists, 233 dental students, and 76 dental hygiene students regarding their knowledge and attitudes concerning child abuse.

Results:
-20% of dentists and 9% of hygienists had reported at least 1 case of suspected child abuse
-83% of dental professionals and 73% of dental students knew they had to report suspected cases of child abuse
-Only 28% of professionals and 18% of students knew where to report suspected child abuse
-Professionals were less likely to know that failure to report suspected abuse was a misdemeanor

Assessment:
There needs to be better awareness in the dental community regarding the suspected child abuse laws and expectations. Perhaps a requirement for CE for current professionals and more in depth testing for students would help the cause.

Monday, June 3, 2013

Risk Factors As Determinanants of Dental Neglect in Children

Resident: Mackenzie Craik

Article: Risk factors as determinants of dental neglect in children.

Author: Stephen A. Jessee, DDS

Journal: Journal of Dentistry for Children, Jan-Feb, 1998.

Key Points: Dental neglect is defined as "failure of a parent or guardian to seek and obtain appropriate and available treatment for caries, oral infections, or any other condition of the teeth and supporting structures that:
   -Make routine eating difficult or impossible
   -Causes chronic pain.
   -Delays or retards a child's growth and development
   -Makes it difficult or impossible for a child to perform daily activities such as playing, walking, or  
   -going to school.

-The diagnosis of dental neglect, except in its most severe forms is sometimes a difficult task.  One publication listed the following indicators of dental neglect:
   -Untreated rampant caries easily detected by a lay person.
   -Untreated pain, infection, bleeding, or trauma affecting the orofacial region
   -History of lack of continuity of care in the presence of identified dental morbidity.

-It is imperative that the dentist be able to distinguish between a parent's or guardian's ignorance of the severity of the dental problem and a deliberate omission of care by a parent or guardian.
-Deliberate neglect legally mandates a report by the dentist.
-Factors that increase the risk for neglect include: single parent homes, marital problems, low socioeconomic status, difficult or erratic temperament in child, child a result of unwanted pregnancy, stress and substance abuse.

Assessment: It will be a very difficult part of our job to confront cases of abuse and neglect, but it is imperative that we try to identify neglected children, and report these cases.  This article was helpful in helping to identify cases of neglect and what constitutes neglect, as well as associated risk factors.


Saturday, June 1, 2013

Oral and Dental Aspects of Child Abuse and Neglect



Resident Name: Todd Bushman
Article Info:
AMERICAN ACADEMY OF PEDIATRICS AMERICAN ACADEMY OF PEDIATRIC DENTISTRY
CLINICAL REPORT
Author: Nancy Kellogg, MD; and the Committee on Child Abuse and Neglect
Title: Oral and Dental Aspects of Child Abuse and Neglect


Main Purpose: The familiarize us with dental aspects of abuse and to help us recognize the signs of abuse.

Key Points:  In all 50 states, physicians and dentists are to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions. This report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may cause suspicion for child abuse or neglect. Physicians receive minimal training in oral health and dental injury and disease and, thus, may not detect dental aspects of abuse or neglect as readily as they do child abuse and neglect involving other areas of the body. Therefore, physicians and dentists are encour- aged to collaborate to increase the prevention, detection, and treatment of these conditions.In all 50 states, physicians and dentists are

Pediatricians should be aware that physical or sexual abuse may result in oral or dental injuries or conditions that sometimes can be confirmed by lab- oratory findings. Furthermore, injuries inflicted by one’s mouth or teeth may leave clues regarding the timing and nature of the injury as well as the identity of the perpetrator. Pediatricians are encouraged to be knowledgeable about such findings and their signif- icance and to meticulously observe and document them. When questions arise or when consultation is needed, a pediatric dentist or a dentist with formal training in forensic odontology can ensure appropri- ate testing, diagnosis, and treatment.

Pediatric dentists and oral and maxillofacial sur- geons, whose advanced education programs include a mandated child abuse curriculum, can provide valuable information and assistance to physicians about oral and dental aspects of child abuse and neglect. Physician members of multidisciplinary child abuse and neglect teams are encouraged to identify such dentists in their communities to serve as consultants for these teams. In addition, physicians with experience or expertise in child abuse and neglect can make themselves available to dentists and dental organizations as consultants and educators. Such efforts will strengthen our ability to prevent and detect child abuse and neglect and enhance our ability to care for and protect children.

Assessment of Article: It is a good article for us because we are mandated to report child abuse when we see it and it is important that we are looking for it.