Wednesday, November 12, 2014

Tooth anomalies associated with failure of eruption of first and second permanent molars

Article Title: Tooth anomalies associated with failure of eruption of first and second permanent molars
Author: T. Baccetti, DDS, PhD Florence, Italy
Date: American Journal of Orthodontics and Dentofacial Orthopedics, December 2000

Major Topic:  Failure of eruption of first and second permanent molars

Main Purpose:  To assess if there is a clinical associations between first and second molars that fail to erupt with other dental anomalies.  Thus leading to possible genetic component that is phenotypic expression for arrested molars.

Introduction:  0.06% of the normal population presents with failure of eruption of first and second molars permanent molars.  Mechanical obstacles are the most common reason, which includes supernumerary teeth, odontomas, and cystic formations.  There has been suggestion that there is a genetic component to these anomalies.  The goal of this paper is to assess the prevalence of clinical associations between failure of eruption of the permanent first and second molars with other types of dental anomalies to point to the additive genetic component.

Methods:  3600 orthodontically untreated subjects from the Department of Orthodontics at the University of Florence was in the initial group.  1080 subjects excluded due to: cleft lip and/or palate or craniofacial malformations, traumatic injuries on the dentition, familial relationships with other examined subject, crowding, nonwhite race. 
Remaining 2520 subjects (1223 males, 1297 females, age range: 12-16 years; mean age 14 years 2 months) were divided into two groups:
·      Experimental: 1520
·      Control: 1000
Both groups were controlled for origin, age and gender distribution.

Failure to erupt was considered complete retention in alveolar bone and under the oral mucosa.  Any participants with mechanical disruption were excluded.

·      Experimental: 26 subjects had failure of eruption (1.7%)
o   Dental anomalies found in these subjects: infraocclusion of deciduous molars, palatal displacement of maxillary permanent canines, rotation of maxillary permanent lateral incisors, aplasia of second premolars, small size of maxillary permanent lateral incisors.  Only 9 subjects had no associated tooth anomaly. 
·      Control: 14 subjects had failure of eruption (1.4%)

Infraocclusion of deciduous molars, palatally displaced maxillary canines, and rotation of maxillary lateral incisors showed a statically significant prevalence (P < 0.001) with those who also had failure to erupt permanent molars.  The gender ratio was M1:F2.25 is similar for palatally displaced canies which have been found to be M1:F1.3 to M1:F3.2. These findings suggest a possible implication of sex chromosomes in the cause of tooth eruption disturbances. 

Discussion:  Further studies are needed to determine if genetics or environmental factors are the contributing factors but there seems to be an additive genetic affect.

The Development of a Dental Anxiety Scale with a Cognitive Component for Children and Adolescents

Authors: Al-Namankany, et al
Journal: Pediatric Dentistry Vol 34/No 7, Nov/Dec 2012

Purpose: To validate a dental anxiety scale with a  cognitive component for use in children and adolescents


  • 14 different self-reported scales have been developed since the 1960s
  • no scale is considered ideal
  • current problems with the scales
    • no cognitive assessment
    • simplistic assessment of most commonly feared factors
    • overly complex self-reported measures
    • issues with validation
    • practicality
    • lack of external validity
  • randomized clinical trial
  • evaluated the effect of video modeling on the behavior or anxious children receiveing dental treatment under IV sedation, inhalation sedation, and non pharmacological behavior management 
  • development of the scale
    • based on data from a systematic review of dental anxiety scales and using principles from 2 books
    • 19 item, cognitive Likert scale (can be used for chilren at least 6 yo)
    • proposed name: Abeer Children Dental Anxiety Scale
    • 3 parts
      • A: 13 self-reported questions that asks about the feelings of the child when facing dental experiences, uses 3 faces as a response set
      • B: 3 self-reported questions that asked about the child's feeling of shyness about  the dentist or the way his/her teeth looked and worry about losing control at the dentist, yes or no answers
      • C: 3 questions answered by legal guardian, for the dentist to report the child's behavior at the end of the visit, yes or no answers
    • inclusion criteria 
      • children with no learning disability
      • must read English or be assisted by an interpreter
      • at least 6 yo
    • 439 children 
Key points:
  • improvements on current scales: 
    • uses only 3 faces
    • investigates the 3 main cognitive thoughts in children
    • other items of dental experience are included
    • validates both clinical and nonclinical situations
    • assesses external validity
  • conclusions:
    • ACDAS is a valid cognitive scale to measure dental anxiety for children who are at least 6 yo
    • ACDAS encompasses the required criteria to be a "Gold Standard" Dental Anxiety Scale for Children and Adolescents

Papillon-Lefevre Syndrome in 2 Siblings: Case Report after 11-Year Follow-up

Title: Papillon-Lefevre Syndrome in 2 Siblings: Case Report after 11-Year Follow-up
Author: Pimental et al.
Journal: Pediatric Dentistry Nov/Dec 12
Type: Case Report

Purpose: To describe the 11-year long-term results of 2 siblings with Papillon-Lefevre syndrome who underwent periodontal and dermatological tx.

Background: Papillon-Lefevre syndrome (PLS) is characterized by hyperkaratosis of the palms and soles, combined with severe periodontal destruction affecting both primary and permanent dentitinos, with clinical onset usually apparent by 2-3 years old. The disease is rare (1-4 cases per 1 million individuals) and is inherited in an autosomal recessive pattern. PLS may occur in siblings, males and females are affected equally and no ethnic predominance is apparent.  Several studies have confirmed that mutations in the cathepsin C gene. The lack of functional CTSC could be associated with an altered response to pathogens. Case reports often show a poor clinical response to periodontal therapy in PLS subjects, and tooth loss leading to edentulism is often inevitable.

Case Descriptions: Patient #1, a 14 year old boy initially presented to the Division of Dentistry and Dermatology of Clinic Hospital in Brazil with palmoplanta hyperkaratosis. The patient reported that all of his primary, and some of his permanent teeth spontaneously exfoliated during childhood. The patient was in full permanent dentition, but teeth #14 and #30 had exfoliated. Periodontal measurements at baseline examination showed high percentages of probing depths 4-6 mm (52%) and >7mm (24%). The plaque index indicated inadequate OH as 64%.
Patient #2 is a 7 year old girl who is the sibling of Patient #1 and was also diagnosed with PLS.  The patient prematurely lost molars and primary incisors (mother indicated child exfoliated teeth from 5-6 years old). Her periodontal status assessment showed poor hygiene (Plaque Index 46%) and no attachment loss of permanent teeth.

Periodontal therapy: Systemic tx began in both siblings with SRP and 500 milligrams of amoxicillin associated with 250mg of metronidazole, 3x daily for 14 days. All periodontally hopeless teeth were extracted. Because the patients lived 300 miles away, periodontal therapy was completed annually for 11 years following the same regimen listed. Sibling 1 exhibited improvement  (pocket reduction of ~21%) but generally had poor OH, which hindered tx and long term success. He subsequently lost his mandibular incisors and #3 and #8. Sibling 2 had much better compliance. She was able to transition from the primary dentition to permanent in which she has been able to retain her teeth.

Discussion: Previous case reports of PLS indicate that subjects will experience tooth loss as a natural consequence of the disease. However, at the same time, other studies have shown that adequate periodontal therapy and tight supportive periodontal maintenance could result in satisfactory healing.  This case report is a prime example of both rationales. The younger sibling benefited being diagnosed early (age 7), however her brother was not as fortunate (diagnosed at at 14).  Considering the recognized decline in polymorphonuclear cell activity and the greater presence of pathogens, PLS-associated periodontitis presents a high rate of periodontal tissue destruction if diagnosed later-on in life.
Unlike his sister, the oldest sibling did not achieve good oral hygiene status; his plaque index was always higher than 40%.  Biofilm control is an effective and essential precondition to achieving periodontal health and successful tx of PLS. Compliance with the treatment protocol had a significant impact on the presence of periodontal pockets and the number of lost permanent teeth.

Conclusion: Nonsurgical debridement associated with antimicrobial therapy appears to be an adequate way to treat these patients. Moreover, when comparing two siblings with PLS described in the present study, importance should be attributed to early diagnosis and good compliance with oral hygiene instruction.

Heart Rate, Salivary Alpha-amylase Activity, and Cooperative Behavior in Previously Naive Children Receiving Dental Local Anesthesia.

                        Date: 11/12/14
Article title: Heart Rate, Salivary Alpha-amylase Activity, and Cooperative Behavior in Previously Naive Children Receiving Dental Local Anesthesia.
Authors: Arhakis DDS et al.
Journal: Pediatric Dentistry V33/No.7 Nov/Dec 12
Type of Article: Experimental study
Main Purpose: To assess the change patterns of salivary alpha amylase (sAA), heart rate (HR) and cooperative behavior in previously naïve children receiving dental treatment under local anesthesia.
·         Activation of the sympatho-adrenomedullary system along with the hypothalamus-pituitary-adrenocortical axis are the 2 primary systems involved with stress response.
o   Activation of these systems leads to increased sAA secretion.
Overview of method of research: 
·         30 children with no prior dental experience that needed 4 or more sessions of dental treatment involving local anesthesia.
o   Patients were asked to refrain from eating, drinking and physical exercise 1 hour prior to dental visit.
o   LA was administered for 120 seconds regardless of type of injection. 0.8 to 1.0ml of 2% Lidocaine with 1:100,000 epi given.
·         sAA, HR, and behavior assessed before, during application of LA and at the end of treatment. 
o   sAA activity sampled with cotton pellet. 5 pellets were soaked on the floor of the mouth until soaked with saliva for approximately 3 seconds.
o   HR was revorded every 15 secondswith an infrared LED sensor pulse oximeter.
o   Behavior was recorded using 2 calibrated observers using the 4 scores of the Frankl score.  
·         Highest SAA values were observed at the end of the sessions. The value was lower in the fourth session.
·         HR always increased during LA administration. This did not vary between sessions.
·         No relationship was found between child cooperation and sAA and HR.
·         Based on sAA activity changes dental treatment with LA in naïve children appeared to be less stressful after 3 sessions.
·         Dental treatment with LA evokes salivary alpha amylase activity and heart rate increases.
·         Correlation between cooperation and HR and sAA activity indicates that cooperative behavior is not a reliable indicator of the stress that the child is experiencing in the dental situation.

Tuesday, November 11, 2014

Effect of Shortening the Etching Time on Bonding to Sound and Caries-affected Dentin of Primary Teeth

Author: Tathiane Larissa Lenzi, DDS, et al.

Published: Pediatric Dentistry V 35/NO 5

Purpose: Evaluate the influence of shortening the etching time of an etch-and-rinse and a 2-step self-etch adhesive system on bonding to sound and caries-affected dentin of primary teeth.

Background: Primary tooth dentin presents chemical and micromorphological differences vs. permanent tooth dentin that may jeopardize adhesion. Greater density of the tubules and larger diameter in primary teeth results in a reduced area of intertubular dentin available for bonding. This results in a thicker hybrid layer and lower bond strength values in primary dentin compared to that of permanent teeth.  A reduced etching time has been suggested for primary tooth dentin to improve bond strengths by the formation of more functional hybrid layers.


Forty-eight second primary naturally exfoliating molars were collected and disinfected. The enamel surface was then removed in order to expose the dentinal layer. Specimens were then randomly assigned to two groups: Sound Dentin (control) and Caries-affected dentin (experimental).  The control group was immersed in distilled water and did not receive pH-cycling; the experimental group was exposed to an artificial caries induction technique that involved pH-cycling to produce a caries-affected dentin surface. After undergoing the pH-cycling process the teeth from both groups were assigned to four sub-groups according to adhesive system (Adper Single Bond and Clearfil SE Bond) and etching time (as recommended by the manufacturer and the recommended time reduced by 50 percent). Resin composite was built-up on the bonded surfaces in ~1.5 mm increments. Specimens were then sectioned and the sections of teeth were then subjected to the microtensile test. Two teeth from each experimental group were then selected to evaluate the etching effectiveness by measuring the hybrid layer thickness through electron microscope interface analysis.

The results showed that etching time did not influence the bond strength to either sound dentin or caries-effected dentin, independent of the adhesive system used. Also, no difference was noted in bonding effectiveness between the adhesive systems. The micro tensile bond strength values were significantly lower for the caries-affected dentin than that obtained for the sound dentin, however. SEM images at the resin-dentin interfaces for both control and experimental groups showed that thinner hybrid layers were produced when the primary tooth dentin was acid etched for 50 percent of the recommended time for both control and experimental groups. The thickness of hybrid layers produced after seven seconds acid etching of carious affected dentin was similar to those produced after 15 seconds of etching of sound dentin.

It appears that prolonged acid etching time tends to lower bond strength by the collapse of collagen fibrils, which prevents monomers from fully impregnating demineralized dentin.  Overall, the results of this study support the statement that use of an etching time reduced by 50% could reduce the occurrence of an unprotected dentin zone along the bottom of hybrid layers and does not jeopardize bonding to either sound or caries-affected dentin of primary teeth.


Title: Intraalveolar Root Fracture in Primary Teeth
Authors: Kim, et al
Journal: Pediatric Dentistry, Nov/Dec 2012
Resident: Avani Khera, DMD

Purpose: The purpose of this study was to assess the effectiveness of long-term resin wire splinting in the management and prognosis or intra-alveolar root fracture in primary teeth.

Introduction: IARF in the primary tooth is rare.  Treatment of IARF in the primary dentition should be considered based on 2 main factor, tooth mobility and displacement of the fractured coronal fragment.  If the coronal fragment is mobile and displaced, the coronal fragment should be extracted to prevent the child from swallowing or inhaling the loos fragment. If the coronal fragment is not displaced, the tooth can be left intact.  Minimal displacement of the coronal fragment can be left untreated and can be expected to be resorbed with reduction of the displaced coronal fragment and immobilization with semi rigid fixation.

Methods: This study was conducted in Seoul, Korea.  The study population consisted of 10 patients with 16 root fractures in their primary anterior teeth.  The data were organized and collected according to: age, gender, injured tooth, clinical appearance, location of IARF, splinting period, resorption rate of fractured fragment, and follow-up period.

Results: IARF occurred 23 times more often in males than females with a mean age of 3.5 years of age.  IARF in primary teeth usually occurred in the middle area.  The mean splinting period was 5.1 weeks and all the teeth were followed up for a long-term period lasting 14-36 months.  Total resorption of the fractured root fragment was observed within 10 months.

Discussion: Unlike in permanent teeth, there is no intention of healing a root fracture in a primary tooth+splint with calcified tissue.  Thus, immobilization of the tooth is recommended only to alleviate sensitivity and for function.  The splinting period for the root fractured primary tooth is between 4-8 weeks—the crown will remain with some mobility until exfoliation.

Sunday, November 9, 2014

Biodentine Used as a Pulp-Capping Agent in Primary Pig Teeth

Anna Abrahamian
November 12, 2014

Article Title: Biodentine Used as a Pulp-Capping Agent in Primary Pig Teeth

Author: A Shayegan, DDS, MS, PhD, et al.

Journal: Pediatric Dentistry, V 34, No 7

Date: Nov-Dec 2012

Major Topic: Pulp Therapy and Pulp Capping

Main Purpose:  The goal of this study was to assess and compare, in primary pig teeth, the pulp response after a pulpotomy using Biodentine, white MTA, or formocresol and repeat the same after direct pulp capping (DPC) using either Biodentine, white MTA, or calcium hydroxide.
Background: Biodentine is a calcium silicate-based cement that has been developed for direct posterior restorations at the University of the Mediterranean in Marseille, Frances. The main component is a tricalcium silicate powder and a liquid solution of calcium chloride. The liquid allows for shorter initial and final setting times and strong mechanical properties. Cytotoxicity and genotoxicity of Biodentine is similar to MTA.

Methods: 180 primary teeth from 9 healthy 4-month old female pigs were each divided into 3 experimental periods (7,28, and 90 days) for each material used for the pulpotomy and DPC treatments (N = for each material per treatment and period).  The pigs were placed under general anesthesia so that pulpotomy or DPC procedures could be performed. Local anesthesia was provided, but rubber dams were not used due to the difficulty in application. The teeth were kept dry with gauze swabs.
Pulpotomy groups: Pulp exposed and coronal pulp removed with round bur. Bleeding controlled with sterile cotton pellets then…
-       FC: 5 min application over pulp stumps
-       WMTA: 3:1 powder/sterile saline mix applied over pulp stumps
-       Biodentin: unit-dose capsule (triturated for 30 sec) then applied over pulp stumps.
DPC groups: All teeth were subjected to a Class V preparation on the buccal surfaces and a pinpoint pulp exposure was made. Bleeding was controlled with sterile cotton pellets then application of…
-       Calcium hydroxide
-       WMTA
-       Biodentine

Following these procedures, the coronal cavities of pulpotomized teeth were filled with IRM then amalgam and the Class V preparations were restored with amalgam only.
The animals were euthanized after 7,28, and 90 days and their haws were prepared for histologic evaluation.  All tissue sextions were examined and evaluated for inflammatory cell response, tissue disorganization, hard tissue formation, and bacteria according to Table 1.

Pulpotomy Groups: In the 7 day-period, the pulpotomy results showed WMTA had less (P<.05) inflammatory cell response than FC. Biodentine also had less inflammatory response (P<.01), than FC.  WMTA and Biodentine had more (P<.01) hard tissue formation than FC. In the 28-day pulpotomy period, WMTA and Biodentine, compared to FC, had less inflammatory cell response (P<.001), less pulp tissue disorganization (P<.05), and more hard tissue formation (P<.001). In the 90-day period, WMTA had less inflammatory cell response (P<.05) as did Biodentine (P<.01), than FC, and both WMTA and Biodentine had more hard tissue formation (P<.01).
DPC Groups:  In the 7-day period, DPC’s results indicate that there was a statistically significant difference between Biodentine and calcium hydroxide in terms of hard tissue formation (P<.05). In the 28- and 90-day period, there was no significant difference between WMTA, Biodentine, and calcium hydroxide in terms of inflammatory cell response, pulp tissue disorganization, and hard tissue formation.
In general, the results showed no statistically significant difference between calcium silicate, calcium carbonate, and zirconium dioxide and WMTA and a comparative success of both materials in pulpotomy and DPC. Conversely, the calcium silicate, calcium carbonate, and zirconium dioxide samples showed a more rapid calcified tissue deposition than the other materials used in this study in the 7-day period, both in the pulpotomy and DPC groups.

Discussion and Conclusions:

A study by Zhao et al. describes “Recently developed calcium silicate-based bone injectable material has been investigated in simulated body fluid conditions. The results showed, by X-ray diffraction and scanning electron microscopy, that calcium silicate stimulated cellular growth and induced hydroxyapatite formation on the surface of the material when exposed to the simulated body fluid.”  The results of this study agree with other in vitro and in vivo studies and show that calcium silicate, calcium carbonate, and zirconium dioxide are highly biocompatible, have bioactive properties, encourage hard tissue regeneration, and provoke no signs of moderate or severe pulp inflammation response.

Wednesday, November 5, 2014

Case Report: Noonan-like Multiple Central Giant Cell Granuloma Syndrome

Case Report: Noonan-like Multiple Central Giant Cell Granuloma Syndrome
Authors: Natalie Bitton DDS. et al. 
Journal: Pediatric Dentistry Sept/Oct 2012
Resident: Margaret Maclin
Article Type: Case Report

Purpose: he purpose of this report was to: summarize the care of a child between the ages of 12 to 16 years old born with Noonan-like central giant cell syndrome and unrelated common variable immune deficiency

Background: Noonan Syndrome (NS) is a genetic disorder that occurs in 1/1,000 - 1/2,500 births. Affects males and females equally and presents very similarly to Turner syndrome. NC is autosomal dominant in inheritance but can also occur as a spontaneous mutation. Common features include: 
  • pulmonary stenosis and other congenital cardiac abnormalities
  • webbing of the neck
  • chest abnormalities
  • bleeding disorders
  • short stature
  • mild mental retardation
  • pectus excavatum
  • undescended testicles in males
  • posteriorly angled and prominent ears
  • high-arched palate
  • facial features that can include any combination of ocular hypertelorism, ptosis, epicanthus, and antimongoloid folds
Because NS varies widely in expression diagnosis is challenging however 45% of cases have a mutation at the PTPN11 gene on chromosome 12q24.1 (However the patient in the report tested negative for this gene mutation).

From birth, the patient suffered many complex health issues from apnea, reflux, bowel obstruction, and an underdeveloped esophagus. At 1 year old, the patient was diagnosed with having a double-chambered right ventricle and pulmonary stenosis, and received reconstruction of the right ventricular outflow tract and a pulmonary valvotomy. Soon after, a dermoid cyst was removed from the patient’s right eye. At 6 years old, the patient had an adenoidectomy and myringotomy. Benign giant cell tumors in the maxilla and mandible were discovered on CT scans. 
The patient was seen regularly by a pediatric dentist, her dental history was unremarkable aside from the GCT found in maxilla and mandible. 
The child was then referred to an oral surgeon, who took panoramic radiographs which revealed:
  • bilateral radiolucencies of the right and left ramus
  • maxillary and mandibular crowding
  • delayed exfoliation and eruption
  • impacted and malposed teeth
  • transposition of tooth number 17 and 18
The oral surgeon provided an open intraoral biopsy of the mandibular lesions, which were identified as giant cell lesions, thus confirming the diagnosis of NS.
The oral surgeon recommended semiannual examinations with panoramic radiographs. At a later date the orthodontia provided two treatment options. 
- Comprehensive orthodontic treatment with fixed appliances and extraction of the maxillary and mandibular first premolars and surgical exposure and forced eruption of the maxillary canines.
- Comprehensive orthodontic treatment with fixed appliances and extraction of the impacted maxillary canines and mandibular first premolars. The maxillary first premolars would be used to replace the maxillary canines.

The second option was selected, and, working in concert the oral surgeon, the orthodontist, family, and child were able to successfully complete the child’s oral surgery and comprehensive orthodontic care. Her recall visits were unremarkable, and her oral health remained excellent.

In February 2006, the oral surgeon extracted teeth numbers 6, 11, 16, 17, 21, and 28 and rebiopsied the giant cell tumor from the left posterior mandible. The histopathology was consistent with a giant cell lesion demonstrating extensive fibrosis. 

During the retention phase of her care, there was a complaint about a palatal swelling. Subsequent to an excisional biopsy  or the benign giant cell lesion, the maxillary retainer was reinserted approximately 1 month later and has continued without problems.  

In June 2010, at 14 years old, the oral surgeon extracted teeth # 1, 16, 18, 31, and 32. The latest panoramic radiograph demonstrated a midline osteolytic process of the palate, which is likely to represent a new giant cell tumor. There has also been progression in the size of the left mandibular giant cell lesion. The patient is now being considered for daily systemic calcitonin therapy to address these new lesions. 

Management of nonsyndromic CGCG includes curettage or resection, which may include loss of teeth. Other nonsurgical modes of therapy including systemic calcitonin therapy, interferon therapy, and intralesional injections of corticosteroids have also been reported with a good degree of success. The recurrence rate for CGCGs ranges from 11-23%.   The initial management of patients with syndromic giant cell lesions is usually not surgical due to the multicentric nature of the lesions and the likelihood that these lesions will become fibrotic and involute over time.