Friday, June 13, 2014

In defense of the oral cavity: The protective role of salivary secretions.

In defense of the oral cavity: The protective role of salivary secretions.

Resident: Hofelich
Journal: Pediatr Dent (2006) 28(2): 110-117
Author: Tabak, L. A

Key Points: 
  • Saliva performs important protective roles in the oral cavity
  • Debate in the 1970s over the "specific" or "non-specific" action of salivary components has given way to current attempts to identify the full complement of all proteins in saliva that are now considered to act together
  • more fundamental protective qualities of saliva :water and pH control
  • Studies conducted over the past 5 decades have documented that at birth, IgA is not detectable in saliva, but levels begin to rise rapidly by 4-8 weeks of age
  • Non-immunoglobulin anti-microbial factors, such as lysozyme and salivary peroxidase  reach adult levels in early childhood
  • Alpha-amylase levels rise steadily throughout the first year of life
  • Salivary film thickness was examined in 5-year-old children by Watanabe and Dawes who reported it to be similar to that observed in adults
  • much more work is needed to understand the development of the innate immune system of the oral cavity
  • Compelling evidence suggests that the acquisition of the commensal flora plays a key role in the gastrointestinal track but in the mouth all bacteria, commensal or not, are coated with saliva. The extent to which the salivary coat plays a role is unexplored. The accessibility of the oral cavity makes it an ideal model to study this and other related questions.

Wednesday, June 11, 2014

Neuropathic Orofacial Pain in Children and Adolescents: Literature Review

Neuropathic Orofacial Pain in Children and Adolescents: Literature Review
Andres Pinto, et al
Resident: Avani Khera

Neuropathic pain may be triggered by a primary lesion or dysfunction in the nervous system. The diagnosis and treatment of neuropathic pain remains a challenge, as no obvious clinical abnormalities are present. Orofacial pain is subdivided into episodic and continuous neuropathic pain.  Episodic pain is characterized by episodes of sudden pain described as an “electric shock” usually lasting a few seconds.  Continous neuropathic pain is constant, ongoing, unremitting pain (rare in children).

Episodic neuropathic pain:

Clinical Presentation:Trigeminal neuralgia is characterized by recurrent attacks of unilateral pain located in the distribution of 1 or more branches of the 5th cranial nerve.  Often a “trigger zone” may stimulate an electric shock, lightning, or stabbing sensation on the upper/lower lip, cheek, chin, or ear.  Glossopharyngeal neuralgia is similar but the pain is located on the posterior tongue, throat, and tonsil/radiates to the ear. 

Pathophysiology: pathological changes that occur in the myelin sheath of nerve fibers causes firing of a focal group of ganglion neurons which become hyperactive.

Evaluation/Diagnosis: Based on combination of clinical examination and brain imaging studies.  The clinical exam consists of both a cranial nerve and thorough intra oral assessment. Differential diagnosis of unilateral orofacial pain in children included pulpitis, TMJ, otitis media, trigeminal/glossopharyngeal/occipital neuralgia, cluster headache, sinusitis.  The child should be referred to a neurologist for an MRI.


Treatment: Pharmacotherapy such as antiepileptic’s may be prescribed. Surgical treatment such as radiofrequency gangliolysis, balloon compression, or cryotherapy may be used.

Examining the Cost-Effectiveness of Early Dental Visits

Examining the Cost-Effectiveness of Early Dental Visits
Authors: Jessica Y. Lee DDS, MPH, PhDl, et al.
Journal: Pediatric Dentistry 28:2 2006
Resident: Margaret Maclin

The purpose of this paper was to review the scientific evidence and rationale for early dental visits. In theory, early dental visits can prevent disease and reduce costs. During the age one dental visit, there is strong emphasis on prevention and parents are given: 

  • counseling on infant oral hygiene
  • home and office-based fluoride therapies
  • dietary counseling
  • information relative to oral habits and dental injury prevention. 
There is evidence that the early preventive visits can reduce the need for restorative and emergency care, therefore reducing dentally related costs among high-risk children. Preschool Medicaid children who had an early preventive dental visit by age I were more likely to use subsequent preventive services and experienced less dentally related costs. These finding have significant policy implications, and more research is needed to examine this effect in a low-risk population.

Findings: 
Children who had their first preventive dental visit by age 1 were more likely to have subsequent preventive visits, but not more likely to have subsequent restorative or emergency visits. Those who had their first preventive visit later (at ages 2 and 3) were more likely to have subsequent preventive, restorative, and emergency visits. 

Rational: 
 1)It is possible that those children who were seen by age 1 were the children of parents who were the most motivated to provide the best possible oral health care for their children. This parental behavior would be expected to carryover into home care, diet, and nutrition; all factors that would lead to improved oral health.
2) Possible relation to a positive outcome from the dental anticipatory guidance given to the parents who took their children to an early preventive visit. Oral health anticipatory guidance has not been the subject of systematic investigation. As in the case of pediatric medicine, however, there are good reasons to assume that early parental education and timely intervention and/or referral can lead to improved health outcomes and reduced costs. 

Because this study followed children for 5 years, one can only hypothesize about what the cost savings would be if this cohort were followed for 10 or 20 more years. If the trend of using more preventive services and less restorative or emergency services holds or increases, the cost impact would be dramatic. with savings in the millions of dollars.

Assessment : Evidence increasingly suggests that, to be successful in preventing dental disease, we as clinicians must begin preventive interventions in infancy. If appropriate measures are applied sufficiently early, it may be possible to maintain our patients in a caries free state. 

Informed Consent: A Stepping Stone in Risk Management

Joseph P. Graskemper, DDS, JD
Compendium Vol. 26, No. 4, April 2005
Resident: Anna Abrahamian

The primary function of informed consent is the protection of the patient’s right to self-determination to accept the proposed treatment. The doctrine of informed consent has been broken into three areas of concern: 1) the question of what information has been given to the patient and how it was presented so that the patient has been sufficiently informed, 2) the question of when a patient is deemed to have consented to treatment or not, and 3) the possible misrepresentations and nondisclosures that occur and affect the patient’s decision.

In order for a patient to be sufficiently informed, the patient must be informed of 1) risks and benefits, 2) the anticipated outcome, 3) the alternatives, and 4) the cost.

With respect to disclosure of risks: 1972 case of Canterbury v. Spence, the court required all material risks to be disclosed to the patient.   Risks are deemed material when a reasonable person in the patient's position would likely attach significance to the risks in question when deciding whether to proceed with a proposed therapy. Before this case, the disclosure of risks relative to the proposed therapy were determined by the standards within the professional community.

With respect to alternatives, the patient needs to be informed of alternative treatments and their risks and benefits, even if they are not the most ideal. It is the patient's right alone to determine what treatment will he performed.  There is always the alternative to leave the problem untreated. As such, the patient should be informed of the possible risks of that decision.

With respect to cost, many lawsuits begin with a misunderstanding about the cost of treatment.  Before any treatment that requires more than one procedure to complete, the patient should be informed of all the costs involved to complete the total treatment proposed.

The most common way to demonstrate a patient's or guardian's consent is with a written consent.  Consent also may be based on the conduct of the patient through his or her willingness to undergo the procedure. The patient must be aware of the need for the treatment, and must act in such a way that the dentist in good faith believed that the patient's actions were a mani- festation ofhis or her willingness or consent; and once the treatment has begun, the patient made no objection to it’s continuation.  Emergencies also lend themselves to implied consent.

Informed refusal:  An entry should be made in the patient’s chart and you can even have the patient sign an informed refusal form.

To avoid many misrepresentations and nondisclosures, do not delegate informed consent to an assistant or hygienist unless they have been properly trained. The dentist should always be available to answer any questions. Consider the invasiveness of the procedure or the amount of risk involved when deciding to delegate the informed consent discussion with the patient.

Physiologic Signs During Dental Treatment in Overweight Vs Normal Weight Children

Resident: Mackenzie Craik

Article: Physiologic Signs During Dental Treatment in Overweight Vs Normal Weight Children

Journal: Pediatric Dentistry, 2008

Author: Chad Hoge, DDS, et al.

Purpose:  This study compared physiologic effects of position change on overweight (OW) and normal-weight (NW) children during preventive appointments.

Methods:  A cross-sectional, case-controlled design assigned a convenience sample to either overweight (Greater than 85th percentile) or normal weight groups (25th to 85th percentile) by body mass index (BMI).  A trained examiner measured blood pressure, heart rate, oxygen saturation, and 5 pulmonary functions in preoperative, upright seated, supine, and postoperative upright seated positions.  Anxiety was measured using the Corah Dental Anxiety Scale.

Results: Normal Weight and Over Weight groups' anxiety scores did not differ. Mean BMI's were 20.1 and 39.7 for normal weight and over weight respectively.  Overall, BP between groups was not different, although systolic BP for OW subjects tended to be higher.  Systolic and diastolic BP dropped for both groups with supine positioning.  During this change, heart rate did not change for NW, but dropped for OW subjects.  Oxygen Saturation was significantly different between groups following position change, but not within each group.  Forced vital capacity and forced expiratory volume were higher in the OW group, but 2 peak expiratory measures were not.

Conclusions: Heart rate and oxygen saturation respond differently to positional changes in overweight patients.

Assessment:  Interesting article, this is a very good article to keep in mind when treating overweight patients in.

Is there a relationship between asthma and dental erosion? A case control study

Resident: Todd Bushman
Article title: Is there a relationship between asthma and dental erosion? A case control study
Author(s): Al-Dlaigan, Y. H., et al
Journal: International Journal of Pediatric Dentistry 2012

Purpose: to determine if there is a relationship between asthma and tooth erosion.

method: The study consisted of 60 children divided into 3 groups as follows: group 1 – control group of 20 children with no history of asthma or other health problems. Group 2 – asthma group – 20 children with a history of asthma requiring long term medication. Group 3 – erosion group – 20 children referred due to significant erosion, no history of asthma. All children were examined clinically and classified as having low, moderate, or severe erosion. Information about medical history and dietary intake was collected for each child through a standard questionnaire. Unstimulated and stimulated saliva samples were collected from the children – the salivary pH and buffering capacity was measured. The data was analyzed using SPSS.

Findings: None of the children in the control group had severe erosion. In the asthma group, 65% had moderate and 35% had severe erosion. In the erosion group, 65% were classified as having severe erosion, with the majority of the erosion occurring on palatal surfaces, unlike in the control or asthma group. In the asthma and erosion groups there were more children who reported a history of indigestion, vomiting, heartburn and stomach problems. Dietary questions showed a high intake of soft drinks in all three groups of children; however, children in the erosion group did have a diet with more acidic components. There was no statistically significant difference noted in salivary flow rates, salivary pH, or buffering capacity between the 3 groups.

Key points/Summary: Conditions such as vomiting, heartburn, and stomach problems were more common in the erosion and asthma groups. Other studies suggest a definite association between gastroesophageal reflux and asthma. The most consistent dietary risk factor related to erosion is the consumption of soft drinks, carbonated beverages, and sports drinks.

Assessment of article good article and very informative.

Sleep disordered breathing in infants and children: A review of the literature.


Resident: Jeff Higbee

Article:  Sleep disordered breathing in infants and children: A review of the literature.

Author: Ivan, J. R., Lefebvre, C. A. and Stockstill, J. W.

Journal: Pediatr Dent (2007) 29(3): 193-200.

 

Purpose: The objective of this report was to review the etiology, diagnosis  and treatment of sleep disordered breathing (SOB) in children and infants.

 

Methods: English peer-reviewed SOB literature identified by MEDLINE and a manual search conducted between 1999 and 2006 was selected.

 

Key Points/Results:

- A delay In treatment of SOB children may be caused by several factors and may result in serious but generally reversible problems. including: (I) impaired growth; (II) neurocognitive  and behavioral dysfunction; and (3) cardiorespiratory failure.

- Adenotonsillectomy is the treatment of choice and continuous positive airway pressure maybe on option for patients who are not candidates for surgery or who do not respond to surgery.

- Minimal information is available concerning the dental treatment of these disorders.  With the devastating effects sleep disorders can have on children and their families, dentists must recognize obvious symptoms and refer these patients for management by physicians.

Pinkham Chapter 11

Pinkham Chapter 11: Dental Public Health Issues in Pediatric Dentistry

Resident: Hofelich
Publication: Pinkham Textbook; Pediatric Dentistry: Infancy through Adolescence, 3rd Edition.
Chapter: 11: Dental Public Health Issues in Pediatric Dentistry

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.

Tuesday, June 10, 2014

Accelerated tooth eruption in children with diabetes mellitus

Resident: Derek Nobrega
Title: Accelerated tooth eruption in children with diabetes mellitus
Authors: Lal S et al.
Journal: Pediatrics (2008) 121: e1139-e1148.

Purpose: To evaluate tooth eruption in 6-14 year old children with diabetes mellitus

Methods:
Tooth eruption status was assessed for 270 children with diabetes and 320 children without diabetes. All teeth were evaluated and categorized into 1 of 6 stages of eruption. Stage 1 – unerupted permanent tooth with primary predecessor present
Stage 2 – unerupted permanent teeth with overlying primary tooth that was mobile
Stage 3 – unerupted permanent tooth that had shed its overlying primary tooth
Stage 4 – permanent teeth emerged with 1/5 of crown visible
Stage 5 – permanent teeth erupted and more than 1/5 crown visible yet not in occlusion
Stage 6 – permanent teeth that were fully erupted
Plaque and gingival inflammation were evaluated in 2 randomly assigned quadrants at 4 sites per tooth.
Key Points
- Children with diabetes exhibited accelerated tooth eruption in the late mixed dentition period (10-14) compared to healthy children.
- For both case patients and control subjects the odds of a tooth being in an advanced eruptive stage were significantly higher in girls than in boys
- There was a trend associating gingival inflammation with expedited tooth eruption in both groups.
- No association was found between the odds of a tooth being in an advanced stage of eruption and hemoglobin A1C or duration of diabetes.
Patients with higher BMI demonstrated statistically higher odds for accelerated tooth eruption, but the association was not clinically significant.
- uture studies need to ascertain the role of such aberrations in dental development and complications such as malocclusion, impaired oral hygiene, and periodontal disease.

Assessment:

This was an interesting article showing a correlation between diabetes and accelerated tooth eruption. This is something we should be aware of and expect when we see patients with diabetes. It will also be good to let parents know about the accelerated eruption so they are not unnecessarily worried if teeth are falling out “early”.

Wednesday, June 4, 2014

Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care

Resident: Jeff Higbee
Article: Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care
Author: Donald C. Bross, JD, PhD
Journal: Pediatric Dentistry – 26:2, 2004

 Purpose: The purpose of this paper was to examine legal issues regarding the management of pediatric dental patients and changing views of proper child care. Standards of care in pediatric dentistry are not static.

Key Points:
- Standards change in response to research, patterns of reimbursement, patient and parental expectations of reasonable care, and consensus among practitioners.
- A major impetus for considering the care of children in all settings has been the increasing recognition of suboptimal children’s care, as well as concerns that children have either been abused or neglected in a number of settings.
- Too often, practices towards children have been untested and based only on the assumption that what is done is “for the child’s own good.”
- Pediatric dentists can respond to changing standards of reasonable care for pediatric dental patients, as expressed in legal decisions.
- Pediatric dentists can also usefully consider how attention to child maltreatment has sensitized parents to be better consumers of services on their children’s behalf.

Assessment:
As pediatric dentists it is our responsibility to always treat each patient with the best care.  Maltreatment can occur in many forms.  As long as we put the patient’s best interest first we can avoid patient mal treatment.

Risk Factors As Determinanants of Dental Neglect in Children

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.

Tuesday, June 3, 2014

LIT REVIEW

Neuropathic Orofacial Pain in Children and Adolescents: Literature Review
Andres Pinto, et al
Resident: Avani Khera

Neuropathic pain may be triggered by a primary lesion or dysfunction in the nervous system. The diagnosis and treatment of neuropathic pain remains a challenge, as no obvious clinical abnormalities are present. Orofacial pain is subdivided into episodic and continuous neuropathic pain.  Episodic pain is characterized by episodes of sudden pain described as an “electric shock” usually lasting a few seconds.  Continous neuropathic pain is constant, ongoing, unremitting pain (rare in children).

Episodic neuropathic pain:

Clinical Presentation:Trigeminal neuralgia is characterized by recurrent attacks of unilateral pain located in the distribution of 1 or more branches of the 5th cranial nerve.  Often a “trigger zone” may stimulate an electric shock, lightning, or stabbing sensation on the upper/lower lip, cheek, chin, or ear.  Glossopharyngeal neuralgia is similar but the pain is located on the posterior tongue, throat, and tonsil/radiates to the ear. 

Pathophysiology: pathological changes that occur in the myelin sheath of nerve fibers causes firing of a focal group of ganglion neurons which become hyperactive.

Evaluation/Diagnosis: Based on combination of clinical examination and brain imaging studies.  The clinical exam consists of both a cranial nerve and thorough intra oral assessment. Differential diagnosis of unilateral orofacial pain in children included pulpitis, TMJ, otitis media, trigeminal/glossopharyngeal/occipital neuralgia, cluster headache, sinusitis.  The child should be referred to a neurologist for an MRI.


Treatment: Pharmacotherapy such as antiepileptic’s may be prescribed. Surgical treatment such as radiofrequency gangliolysis, balloon compression, or cryotherapy may be used.

A comparison of Oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children

Resident: Todd Bushman
Article Title: A comparison of Oral health status and need for dental care between abused/neglected children and nonabused/non-neglected children
Journal: Pediatric Dentistry, Jan/Feb 1994; 16:1
Authors: Patrice Greene, et al.
Main Purpose: Compare the oral health status of untreated, decayed permanent teeth in abused/neglected children with nonabused/non-neglected controls.
Methods: A case sample of 30 abused/neglected children was drawn from the social services registry at a major military medical center. A group of control children was drawn from a general oral health survey of grade school school children at the same military base. Total sample size was 903. Controls matched to cases based on key demographic characteristics. Oral health status of children was assessed by two calibrated dentists using the DMFS index.
Key Point: The odds that abused, neglected children have decayed/untreated teeth are 8 times greater than nonabused, non-neglected children.
Assessment: As we come across reported cases of child abuse, these children should be screened/monitored regularly as their caries risk is higher than that of non-abused children.

Monday, June 2, 2014

Legal issues affecting dentistry's role in preventing child abuse and neglect

Resident: Derek Nobrega
Title: Legal issues affecting dentistry's role in preventing child abuse and neglect
Authors: LD Mouden and DC Bross
Journal: JADA 1995;126(8):1173-1180

Main Purpose: To discuss the dentist’s role in identifying, preventing, and reporting child abuse and neglect in dental patients.

Key Points:
- In every state, certain citizens are specifically listed as mandated reporters-those individuals required to report suspected cases of child abuse and neglect (including dentist). Child maltreatment includes physical abuse, physical neglect, sexual abuse, emotional abuse and neglect.
-Almost every state statute contains a penalty for failure to report suspected cases.
- 65 percent of all cases of physical abuse involved injuries to the head, neck or mouth, but dentists have made less than 1 percent of all reports.
- It is now known that child maltreatment occurs in families at all economic levels and from every ethnic background.
- The majority of states exclude exclude reasonable corporal punishment from the definition of abuse.
- From the beginning of their professional education, health care providers are told that what is discussed within the doctor-patient relationship is confidential. However, child abuse reporting laws systematically remove doctor-patient confidentiality requirements in suspected abuse cases.
- The American Academy of Pediatric Dentistry has defined dental neglect as the failure to seek treatment for untreated, rampant caries; trauma; pain; infection; or bleeding. Also included in this definition is the failure of parents to follow through with treatment once they have been informed that the above conditions exist. Many parents have expressed to practitioners that they were totally unaware of conditions in their child's mouth before receiving the dentist's diagnosis. Therefore, parents' failure to follow through with treatment is probably more important for a determination of dental neglect than is their lack of knowledge.
- The ADA Principles of Ethics and Code of Professional Conduct states as follows: "Dentists shall be obliged to become familiar with the perioral signs of child abuse and to report suspected cases to the proper authorities consistent with state laws."

Assessment: Good article highlighting the dentist’s position to identify signs of abuse and neglect. It is not up to us to determine if abuse or neglect is occurring, but to be aware of the signs, and understand the proper authorities who need to be informed.