Tuesday, September 30, 2014

Assessment of Noise Exposures in a Pediatric Dentistry Residency Clinic

Anna Abrahamian
October 1, 2014

Article Title: Assessment of Noise Exposures in a Pediatric Dentistry Residency Clinic

Author: K Jadid, DDS, et al.

Journal: Pediatric Dentistry

Date: July-August 2011 (Volume 33)

Major Topic:  Occupational Noise Exposure

Main Purpose:  To compare typical noise exposures in a pediatric dental clinic to the OSHA action level  (AL = 80 dBA) and permissible exposure limit (PEL = 90 dBA) as well as to measure the daily combined noise level that was produced by dental instruments and young children and to which one resident was exposed in a pediatric dentistry residency clinic.


Over 6 weeks, noise dosimetry samples were obtained for 31 standard workdays of a pediatric dentistry resident in a hospital-based program.  During those days, the resident performed procedures that are typically done by pediatric dentists on a daily basis. A comprehensive noise dose, time weighted average (average of the sampled sound over 8 hours), and average noise exposure levels for each of these 31 days were obtained. The average recording time per day was 7.6 hours.  The resident was also responsible for keeping a daily exposure logbook with information about his clinical activities and specific encounters of noisy events (ex: 10;15am, screaming during a lap exam, etc). The noise dosimeter was calibrated before and after each day’s use to ensure accurate results. Noise spikes that could not be mated with noisy activities in the exposure log were excluded from the analysis. The data were analyzed to determine the frequency of days during which the maximum noise levels exceeded 90dBA and whether daily noises exceeded the OSHA action level, PEL, and/or NIOSH reference limits.

On any particular day during the sample period, the OSHA AL and PEL were never exceeded, however the average sound levels of noise produced when children cried during lap exams, papoose board treatments, and during unsuccessful sedations were 88.3, 90.1, and 86.3 dBa, respectively.  The high-pitched sounds of children in the dental operatory routinely reached maximum levels in excess of 98dBA.

During some days, the noise exposure exceeded 50% of the OSHA and NIOSH standards for exposure.  Some values recorded were higher than the noise levels produced by dental instruments, including ultrasonic scalers.  This suggests that the potential for hazardous noise exposure exists, especially if working for extended shift durations or if a greater number of crying/screaming patients are encountered or if episodes of crying/screaming are extended.  The maximum sound level sampled never exceeded the OSHA ceiling limit of 115dBA.  Even moderate levels of noise, however, potentially contribute to a stress reaction, interfere with sleep, lower morale, reduce efficiency, create annoyance, interfere with concentration, or result in premature fatigue.  The data suggest that pediatric dentists may be at risk for incurring these non-auditory noise effects.  The study also suggests that dentists who predominantly treat children are exposed to overall higher noise levels than other dentists because children themselves produce significant sound in addition to the noise of dental instruments.  As a consequence, when exposed for extended periods of time, these providers are potentially at a higher risk for auditory side effects – tinnitus, temporary hearing loss, and permanent hearing loss (all noise induced hearing loss – NIHL).


Given the study’s results, I think that it is important to raise awareness to reduce the risk for NIHL.  We should consider strategies to reduce noise exposure during the workday as well as after hours to minimize it’s adverse health effects.

Solitary Median Maxillary Central Incisor: A Report of 2 Cases

Article Title: Solitary Median Maxillary Central Incisor: A Report of 2 Cases
Authors: Sekerci et. al
 Journal: Pediatric Dentistry Mar/Apr 12
Type: Case Report.

Puprose: To report the dental findings of 2 children with single median maxillary central incisor.

Solitary median maxillary central incisor (SMMCI) is a rare dental anomaly that can occur in either the primary or secondary dentition. The prevalence of live-born children with SMMCI is determined to be 1:50,000. The etiology of SMMCI remains uncertain. The most common cause of an absent maxillary central incisor is trauma or, more rarely hypodontia.

Case I: A 14-year old male patient presented with orbital hypotelorism, indistinct philtrum of the upper lip, a SMMCI, and an absent maxillary labial frenulum. The maxillary arch was V-shaped, and a mild prominence of the mid-palatal ridge was observed. He had a skeletal Class III relationship, and there was some sign of nose block and mouth breathing. The craniofacial morphology in the patient showed short maxillary length, a retrognathic and posteriorly inclined maxilla, and a normal and posteriorly inclined mandible. Other perminant teeth were developing normally.
Case management involved orthodontic, surgical, and prosthodontic tx. Extraction of the maxiallary second premolars and use of a full-coverage, maxiallary arch expansion to create space for the missing central incisor to one side of the midline. After surgical tx , a single tooth implant will be placed.

Case II: A 14-year old femaile patient was referred due to dental caries and eating difficulty. IOE revealed significant decay, high maxillary U-shaped arch, and mild prominence of the mid-palatal ridge. She had orbital hypotelorism, and an indistinct philtrum of the upper lip, a SMMCI, and the maxillary labial frenum was absent.  She was satisfied with the appearance of her teeth and was not aware of orthodontic problems. She also had nasal septum deviation. 
The patient was happy with her appearance and only wanted her dental decay treated. However, ideal tx would have included extraction of her maxillary first premolars would provide sufficient space for the missing central incisor to one side of the midline. An alternative option was distalization of her maxillary first molars via cervical headgear. Additional tx would include single tooth implant (at age 17-18), or a bridge.

Discussion: Etiology of SMMCI has so far not been precisely determined. Yassin et al., reported that it may be due to a congenitally missing bud with agenesis of the incisor, and the remaining incisor erupts in the midline. Hall et al., suggested that insufficient lateral growth from the midline on about the 37th or 38th day of pregnancy results in premature fusion of the epithelial dental lamina, and therefore 2 central incisor teeth is prevented. Another hypothesis is that 1 tooth consisting of 2 normal distal havles of the central incisors matures from the fused enamel knots subadjacent mesenchyme of these teeth buds.

Several known syndromes have been recorded in SMMCI patients, including ectodermal dysplasia, Duane retraction syndrome, velocardiofacial syndrome, CHARGE syndrome, and the most severe being HPE (haloprosencephaly). HPE is a complex brain malformation resulting from incomplete cleavage of the prosencephalon, occurring between the 18th and 28th day of gestation and affecting both the forebrain and the face. All HPE patients have SMMCI, but not all SMMCI patients have been diagnosed with HPE.

To treat SMMCI, ideal management (following diagnosis and genetic counseling) requires good pediatric dental care if only SMMCI and mild nasal airway narrowing present. Facial growth analysis  (including transverse and sagittal facial growth) and photographic series should be included in the usual dental tx plan. No tx is necessary in the primary dentition.

In the permanent dentition, the orthodontist will use a palatal expander to provide sufficient space for the missing central incisor. Distalization of the maxillary first molars or extraction of the first premolar provides enough space for the contralateral artificial central incisor with either a single tooth implant, or by a bridge/denture.  In some cases, extraction of the central incisor and mesialization of the laterals and reshaping the laterals, canines, and premolars may be required.

Early diagnosis of SMMCI is important, as it may be a sign of other severe congenital or developmental abnormalities, especially HPE. Referral to a pediatrician for further investigation is crucial.

Overdenture for Total Rehabilitation in a Child with Early Childhood Caries

            Date: 10/01/2014

Article title: Overdenture for Total Rehabilitation in a Child with Early Childhood Caries

Authors: Bolan et al.

Journal: Pediatric Dentistry V33/No.2  Mar/Apr 12

Type of Article: Case report

Main Purpose: Present a clinical case of an overdenture in a 3 year-old patient with early loss of his primary maxillary teeth due to early childhood caries.

Case Report
·      Dalla Bona retention system used- upper right canine was used as retainer.
·      3 year-old male missing all maxillary teeth except the right canine.
·      Lower arch all teeth were present except the primary left first molar.
·      Second molar not erupted yet.
·      Right canine was treated endodontically and prepared for installation of an over-denture.
·      Maxillary alginate impression done to obtain preliminary cast for an acrylic tray for final molding with condensation silicone (Impregum).
·      Wax rims fabricated and placed in patient’s mouth.
·      Cast mounted on articulator and the teeth were selected during the previous visit were prepared as primary teeth and placed in the wax rim.
·      Intraoral clinical assessment of occlusion and the position of the prosthetic teeth were performed.
·      After prosthesis fabrication a niche was made in the region of the canine to enable the insertion of a metallic capsule.
·      A metallic post containing the “male” part of the system was cemented in the endodontically treated canine root canal with resin, based cement. 
·      Female socket was transferred to the prosthesis.
·      Follow-up: 1 week, a month, and every 6 months.
·      The canine with the overdenture’s retainer has been radiographically monitored every 6 months to assess physiological resorption.

·      The patient and mother were satisfied with the treatment.
·      Advantages of the overdenture over conventional total prosthesis: increased stability and support, accentuated the muscle “feedback” and proprioception, gives increased comfort when chewing and speaking and preserved the tooth and the alveolar bone.
·      Problems: child cooperation.
·      The use of removable prosthesis in children during growth phase should be examined periodically.

o   Rebase and remake may be needed.

Review: Child abuse

Child Abuse and Neglect: Current Concepts.
American Board Article. Issue 332(21), 1995.
Author: Wissow, LS.
Resident: Avani Khera

Purpose: To review diagnostic and therapeutic issues posed by child abuse and neglect.

Definitions and Epidemiologic Features:
- Child maltreatment is intentional harm or a threat of harm to a child by someone acting in the role of caretaker, even if only for a short time.
- Maltreatment is divided into 4 groups: physical, sexual, emotional, and neglect.
- Neglect is the most common of the 4 types.
- Incidence of sexual abuse is found in all SES groups evenly, Neglect and physical abuse are found more often with increased level of poverty.
- Child abuse and neglect normally occur together with other forms of abuse in the home, such as spousal battery and violence between siblings.
- On average about 1.4 million US children under 18 (2.3%) undergo some form of child maltreatment every year.
- Though 80% of the deaths resulting from maltreatment occur in children under the age of 5, the incidence of physical and emotional abuse has been shown to increase with age.
- Social and emotional handicaps are the most serious long-term consequences of maltreatment.
- Physically abused children are generally more aggressive with their peers than those who have not been abused, have more troubled interpersonal relationships, and have more depress and aggressive symptoms and affective disorders.
- Sexual abused kids also have increased frequency of anxiety disorders and problems with sex roles and sexual functioning.
- As adults, children that have been abused suffer two to three times as much from drug abuse and depression as members of the general population.

Detecting Abuse and Neglect:
- Child care providers can detect maltreatment by creating an atmosphere that encourages disclosure and by learning to ask directly and empathetically whether maltreatment is taking place.
- A good history, psychological and medical from parent and child is key.

- One approach would be to view the presenting form of maltreatment as only a symptom of underlying disorders that must be uncovered before a long-term therapeutic plan can be divided.
- Treatment may involve working with the family as a unit and working separately with individual members.
- Formal and informal tx teams usually include social workers, mental health professionals, attorneys and community aides, in addition to medical personnel.
- Tx appears not to work that well with adults who abuse their children. 30% were found to continue abusing their children even during tx.
- Positive results have been shown for some education programs for physically abusive and neglectful parents and preventive home visits to young mothers who otherwise appear to be at risk for abusing their children.
- Tx results in children also appear to be mixed. Foster care, which would normally guarantee safety from the physical abuse might result in permanent separation of the child from the family, and this to a child may be more traumatic than being left with his abusive family.
- Family-preservation programs have thus become more popular, since they keep the child in the home while changing the home environment for the better.

ulp Canal Obliteration Following Trauma to Primary Incisors: a 9-year Clinical Study

Title: Pulp Canal Obliteration Following Trauma to Primary Incisors: a 9-year Clinical Study
Authors: Santos, et al
Journal: Pediatric Dentistry, Sep/Oct 2011
Resident: Avani Khera, DMD

Purpose: The purpose of this study was to determine the occurrence of PCO in traumatized primary maxillary incisors and its association with secondary pulp necrosis, type of trauma, and further incidence of trauma.

Introduction: Studies report a prevalent ranging from approximately 1-36%.  Obliteration is a response of live pulp to dental trauma, which can trigger hard tissue deposition within the pulp chamber and root canal space.  It is usually found in a radiographic image after disappearance of the root canal space.  Clinically, the crown will have a yellowish color. Pulp necrosis may occur.

Methods: A retrospective descriptive study on 122 traumatized teeth was carried out (9 year follow up) using the clinical and radiographic data from 82 patient charts.  The radiographs and exams were carries out at 15, 30, and 90 days as well as 5, 8, and 12 months post trauma.  After 1 year, follow up was completed every 6 months until complete eruption of the permanent successor.

Results: Among the 112 traumatized primary maxillary central incisors, 54% exhibited PCO and 46% did not.  39% exhibited discolorations while 26% were yellow and 15% were grayish. PCO was not significantly associated with gender, age, or type of trauma. The association between PCO and crown discoloration was significant.  There were no cases of secondary pulp necrosis. 

Conclusions:  There was a high incidence of pulp canal obliteration in the present study, the type and recurrent of trauma were not risk factors, and there were no cases of secondary pulp necrosis among the obliterated teeth.

Wednesday, September 24, 2014

Title: Continued Care of Children Seen in Emergency Department for Dental Trauma

Title: Continued Care of Children Seen in Emergency Department for Dental Trauma
Authors: Gustafson, DDS, MS. et. al.
Published: Pediatric Dentistry Sept/Oct 2011
Article Type: Retrospective Study
Resident: Margaret Maclin, DMD

- To determine the rate of continuing care for dental trauma patients seen after-hours in a hospital emergency department (ED). 
- Identify predictors for seeking continuing care. 
- Identify barriers for seeking continuing care.


- "Dental trauma in children is a serious dental public health issue"
- In a 10 yr study of over 9500 cases of craniomaxillofacial trauma
        *nearly 50% involved a dentoalveolar component. 
        *Up to 50 percent of 5 -18 year olds will incur some type of dental injury during their school  years.

- Substantial life-long costs are associated with the replacement of teeth lost to trauma in childhood. 
- Using the most recent cost data available, estimates range from $20,000 to $35,000 to replace a single tooth lost during adolescence. 
- Records of 856 patients treated at Nationwide Children’s Hospital ED for dental trauma between September 2003 and December 2007 were screened for trauma. 
- Traumas included were avulsion, luxation, and intrusion injuries. 
- 175 qualifying patients were included based on injury and root development. 
- A quality assurance survey was conducted with 96 parents of these patients to determine barriers and predictors for follow-up treatment. 

- Patients averaged 2.5 follow-up visits at Nationwide Children's Hospital. 
- The most commonly reported barriers to receiving treatment were: 
         *having to miss school (21%), 
         *taking time off of work (17%)
         *costs associated with dental care (13%). 
- No statistical significance was found between number of follow-up visits and the patient retaining the injured tooth. 
- The number of follow-up visits was not significantly different between patients with private and public insurance. 

School, work, and costs associated with ongoing trauma management affect follow-up compliance irrespective of payment source.  

I thought it was interesting to see that the main factor we think affects treatment was found to not be a significant management factor for this study. 

Old Drugs, New Uses

Title: Old Drugs, New Uses
Authors: Marcio A. da Fonseca and Paul Casamassimo
Journal: Pediatric Dentistry Jan/Feb 11
Type: Literature Review

Purpose: The purpose of this paper was to identify several areas in which existing, often well-known medications with clearly a defined purposes have been employed to manage different conditions and diseases in children.

Introduction: Advances in therapy have led to more children and adolescents with chronic diseases and conditions to enjoy longer healthier lives. Medications used solely in adults are not being prescribed for young patients, often without approval (“off-label use”); In fact, as much as 50% of pediatric use of medications is considered off-label.  Many clinicians and researchers have learned that many drugs originally administered for one purpose, have an unexpected positive effect on another.

Antiepileptic Drugs: Original Use – Epilepsy; New Use- Neurological conditions, psychiatric disorders, pain syndromes, eating disorders (Valproate, gabapentin, and pregabalin increase appetite)

Antiepileptic drugs (AED)- have been used to manage other neurological conditions, psychiatric disorders, and pain syndromes. AEDs may be able to dampen many proposed cause of chronic pain, such as peripheral and central sensitization, hyperexcitability, and neuronal disinhibition.  AEDs may cause adverse effects of concern for the pediatric dentist, such as: blood dyscrasias; increased oral secretions or dry mouth; behavioral change; liver dysfunction; and gingival overgrowth.

Bisphosphonates: Original Use – Postmenopausal and steroid induced osteoporoses; New Use – Primary and secondary osteoporoses, hypercalcemia of malignancy, metastatic bone disease in cancer, multiple myeloma

Bisphosphonates strongly bind to hydroxyapatite crystals and reduce bone resportion by inhibiting cell functions and inducing accelerated osteocalst death. Osteoclasts only are affected by the superficially bound drug, and BIS buried in bone are biologically inert with a half life of several years. There is insufficient evidence to suggest that implant placement, tooth extraction, and other surgical tx should be routinely avoided for patients receiving oral forms of the drug. However, use greater than 3 years does increase the development of BRONJ.  IV BIS is associated with delayed tooth eruption in children with OI and with ulcers when pills come in direct contact with the oral cavity.

Botulism Toxin: Original Use – Strabismus, blepharospasm; New Indication  - hyperhydrosis, cervical dystonias, facial frown lines, spaticity, hyperlacramation, bruxism, rhinitis, hemifacial spasm, Tourettes syndrome, incontinence, salivary secretory disoder, trismus myofacial pain, headache

Botulism is  food poisoning caused by Clostridium botulism, a gram-positive anaerobe that is found in soil and water. The neurotoxin proteins have the ability to inhibit the release of acetylcholine from the presynaptic nerve terminal, causing local chemodenervation. All uses of Botulism in peds is off-label use. In dentistry, bruxism can be managed with BT injections in the masseter and temporalis muscle. Some side effects dentists should be aware of with BT are, disphonia, dysphagia, diplopia, ptosis, flu-like symptoms, generalized muscle weakness, skin rashes, fatigue, dry mouth, reduced sweating, and constipation.

Hydroxyurea: Original Use – Psoriasis, polycythemia vera, cancer, thrombocythemia; New Use – Sickle cell disease

Hydroxyurea has shown an increase in its use to treat sickle cell disease. HU is efficacious in the treatment because it increases the production of fetal hemoglobin-contiaining erythrocytes. Its use in adults has been very strong, but not yet in the case of children, however there is encouraging data. Children who have SCD and are treated with SCD may develop cutaneous and oral squamous cell carcinomas and basal cell carcinomas have been reported following HU administration. 

Intravenous Immunoglobulin: Original Use – Infectious diseases, congenital immunodeficiences, hypogammoglobulinemia; New Use – Pediatric HIV, ITP, Kawasaki disease, CLL, prevention of GVHD (graft vs host) and infections in HSCT, Guillain-Barre syndrome, autoimmune diseases

IV Immunoglobulin is the product that is physiologically and pharmacologically the same as immunoglobulin in the human body as it is purified from human plasma leading to a relatively pure concentrate of IgG.  It was originally used to treat infectious diseases, congenital immunodeficiency, and hypogammoglubinemia. Also known to increase platelet count (tx idiopathic thrombocytopenia purpura

Methotrexate: Original Use – Cancer; New Use - Juvenile idiopathic arthritis, psoriasis, inflammatory bowel disease, prevention of GVHD in HSCT

MTX is a folic acid analog that inhibits dihydrofolate reductase, an enzyme needed for DNA synthesis, repair, and cellular replication. Traditionally used to tx cancer, MTX has been increasingly used in low  dose regimens for a variety of non-cancerous conditions. Pediatric dentists should be aware that the drug may induce or exacerbate a wide variety of oral lesions, ranging from nonhealing ulcers to destructive lymphoma-like lesions.

Thalidomide: Original Use – Epilepsy, sedation, antiemetic in pregnancy; New Use – leprosy, multiple myeloma, myelodysplastic syndrome, Behcets disease, SLE, apthous ulcers, tx of post- HSCT GVHD

Thalidomide- was originally synthesized as an anticonvulsant agent but was found to be an effective sedative and sleep-inducing agent.  Thalidomide and its immunomodulatory analogues affect the body’s immune system in many ways, including potential anti-inflammatory and anttcancer properties. The drug is a useful option in children with Bechets disease whose severe oral and genital lesions are unresponsive to other treatment.

Latex Allergy: A Relevant Issue in the General Pediatric Population

Resident: Hofelich

Author: M. H. Lee, DDS, et al.
Journal: Journal of Pediatric Health Care
Year: 1998.

Key Points
  • Although latex allergy is a widely recognized problem of the pediatric myelomeningocele population and of frequent users of latex products, it is often overlooked in the general pediatric population.
  • prevalence of latex in common household items and in medical environments increases one's exposure and therefore one's possibility of sensitization to latex
  • latex allergy may range from mild local reactions (erythema) to more severe systemic reactions (asthma or anaphylaxis)
  • The immunoglobulin E-mediated mechanism of these reactions has been confirmed serologically by the presence of latex-specific immunoglobulin E with radioallergosorbent testing.
  • avoidance of latex is currently the only way to prevent reactions
  • inadvertant exposure is not uncommon - Medic-Alert bracelets and an Epi-Pen should be provided for children allergic to latex
  • Pediatric nurses should consider latex allergy as a possible diagnosis in situations of unexplained allergic or anaphylactic reactions and should be aware of optimal therapeutic interventions.

    Assessment: Good article reminding us of the general risks involved with latex allergies and the pediatric population.

Tuesday, September 23, 2014

Hierarchy of Research Design Used to Categorize the “Strength of Evidence” in Answering Clinical Dental Questions

Anna Abrahamian
September 24, 2014

Article Title: Hierarchy of Research Design Used to Categorize the “Strength of Evidence” in Answering Clinical Dental Questions

Author: RF Jacob, DDS, MS, et al.

Journal: The Journal of Prosthetic Dentistry, Volume 83, No 2 (“Classic 100” Article #86)

Main Purpose:

The purpose of this article is to highlight important features of research design that clinicians can use to determine which articles are useful when attempting to answer clinical questions and determine the best therapy for their patients.


The article categorizes the quality of research reports by a “research design hierarchy.” Each research design has a position in the hierarchy based on strengths/weaknesses of the study.  The authors state that when the ideal design is used, the strength of the conclusions are great and this exemplifies the “best available evidence” for making treatment decisions.

Some important definitions:
Internal validity: the correctness of the study results for the study population. Influenced by how well the methods, outcome measurement, and data analysis is carried out. It is threatened by bias and random variation.
External validity: “generalizability”, the ability to generalize findings in a sample population to an external population.

The research hierarchy classifications are based on 3 features of study design: 1) the manner in which the subjects were assembled for the test groups, 2) whether exposure to the intervention was under the control of the investigator, and 3) whether the outcome of interest was present at the time of enrollment. These features are all influenced by bias and random variation. The high the study design ranks in the research hierarchy, the better the study minimizes bias and distributes random variation equally between groups.  The authors classify studies into groups A through D based on these parameters.

Group A: exposure to intervention/putative causal factor is under control of investigator, a control group is present, and the outcome is not present at the tie of study enrollment. Randomized clinical trials are group A studies and this places them at the premier position of the research hierarchy.
Group B: exposure to the intervention may not be under the control of the investigator, there is a control group (it may or may not be concurrent), and the outcome is not present at the time of study enrollment. Prospective cohort trials and before-after studies are group B studies.
Group C: exposure to intervention not under control of investigator, there is a control group (it may or may not be concurrent), and the outcome is not present at the time of study enrollment. Cross-sectional (restrospective) studies are group C studies.
Group D: exposure to the intervention not be under the control of the investigator, there is no control group, and the outcome may be present at the time of study enrollment. Descriptive studies and expert opinions fit this categorization.

Conclusion: Prospective randomized clinical trials offer the best possible evidence to determine the truth about a maneuver exposure. Dentistry has a preponderance of literature using groups B, C, and D. The greatest value of these reports is that they offer experience and knowledge on the maneuver and outcome to assist in designing a definitive randomized clinical trial.