Wednesday, January 28, 2015

A performance Measurement Plan for Pediatric Dentists: Using Accuracy of Caries Diagnosis from Intraoral Radiographs

Article Title: A performance Measurement Plan for Pediatric Dentists: Using Accuracy of Caries Diagnosis from Intraoral Radiographs
Author: Hanry O. Ohiomoba, BDS, MPH, Linda P. Nelson, DMD, MScD
Journal/Date: Pediatric Dentistry, Vol. 35 No. 1 Jan/Feb 2013
Resident: Slowikowski

Major Topic:  Performance Measurements

Main Purpose:  Develop a metric to measure: 1) an individual pediatric dentist’s performance against peer performance and 2) aggregate group performance; using accuracy of caries diagnosis

Introduction:  In 2007, Boston Children’s Hospital asked all surgical department heads to evaluate their individual providers against a group of their peers by utilizing a performance metric.  This is provides information for credentialing, data for third party payers, and as a way to assess quality improvements.  The medical field has many of these assessment tools in place and we find dentistry less so.  Diagnostic accuracy was chosen due to the literature showing that there is a wide variation in diagnosis of caries from intraoral radiographs among dentists.  

Methods:  Standard was set that interproximal caries was defined as a lesion that was half way through the dental enamel and occlusal caries was any lesion that was visible from the occlusal surface on the radiograph.  Conventional (non-digital) bitewing radiographs were used, all taken on a patient 6 y/o or younger. 

3,985 surfaces were used; data was collected from all operating room procedures performed between October 2007 and December 2010. 

9 pediatric (4 full-time, 5 part-time) attendings were calibrated.  Scorecard was developed for data collection, which contained a matrix of teeth #A-T, surfaces were mesial, large occlusal, distal.  Response choices were yes or no.  Three pediatric attendings rated the surfaces.  1 provider and 2 randomly selected peer pediatric dental attendings (reviewers).  3 scorecards were collected for each patient.  Data was entered into an Access 2003 database and was analyzed by SAS 9.2 software.

Results:  Total tooth surfaces assessed per provider varied due to number of patients treated.  Per provider acceptable diagnosis was between 89%-96% and overall for the department it was 95%.  Using the 95% confidence interval the department acceptable diagnosis ranged from approximately 94-95%.  There was secondary analysis completed with the criteria that all three reviewers had to agree.  No significant change was assessed.  The caveat was that 436 cases were thrown out when the two reviews didn’t agree.  It was also not able to look at the surfaces that were in agreement, meaning that much to the agreement was upon non-carious surfaces. 

Additional interesting findings:
·      Years in practice tend to influence the attending tendency to over or under-treat.  4 attendings with average of 8 years of practice experience 1.52 times more likely to overdiagnose compared to 5 attending with an aver of 27 years of practice experience. 
·      Gender predilections: males were 1.2 times more likely to overdiagnose then females, but whenever an unacceptable diagnosis was made is was more likely to be overdiagnosis and there was no gender difference.

Most treatment rendered due to high caries risk of patient was a stainless steal crown (SSC) per the American Academy of Pediatric Dentistry guidelines.

Conclusion: Accuracy of caries diagnosis from intraoral radiographs is a useful metric.  Calibration and periodic reporting of diagnostic accuracy is important to achieve high level of quality care.  Use of SSC’s helps with issues that might arise from underdiagnosis in a high-risk population that are treated in the operating room.

Discussion:  Interesting article.  I originally wanted to blame the calibration for the good out come but in the results section there was mention of the differences between attending.  Having equal number of tooth surfaces assessed may have changed the results.  It shows us that continual assessment of our radiographic diagnosis is important in providing appropriate care.

Management of Space Problems in the Primary and Mixed Dentitions

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

Author: Peter Ngan, DMD et al.

Journal: Classic 100 Articles, #43

Major Topics: Space Maintenance, Growth and Development

Background: Crowding and irregularity are the most common components of malocclusion in dental patients. This article gives an update on the current knowledge of space management.

Crowding Definitions – Simple and Complex Categories:
Simple: "disharmony between the size of the teeth and the space available in the alveolus with no skeletal, muscular, or occlusal functional features", it is most frequently associated with Class I malocclusion.
Complex: "crowding caused by skeletal imbalance, abnormal lip and tongue functioning, and/or occlusal dysfunction as well as disharmony between the sizes of the teeth and the available space."
Etiology: The exact cause of crowding or malocclusion in general is unkown.

Eruption Sequence:
Most favorable sequence of eruption to obtain a normal molar relationship according to Lo and Moyers:
Maxilla: first molar, central incisor, lateral incisor, first premolar, second premolar, canine, second molar (6124537). 
Mandible: first molar, central incisor, lateral incisor, canine, first premolar, second premolar, second molar (6123457).

Most unfavorable sequence in the maxilla:
Second molar erupts earlier than either of the premolars.

Most unfavorable sequence in the mandible:
Canines erupt later than the premolars.

Space Analyses:
Conventional Space Analysis (Canine Space Analysis):
-       Proposed by Nance (1947)
-       Space available is estimated by measuring the arch perimeter from the mesial contact of the permanent first molar from one side of the dental arch to the mesial contact of the permanent first molar on the opposite side of the dental arch (contour an arch wire to the line of occlusion and the straightening it out).
-       Space required is summation of the mesiodistal widths of the erupted mandibular permanent incisors and the estimated widths of the unerupted permanent canines and premolars (from radiographs or a prediction table, or both).

Tanka and Johnston Analysis: (no radiographs or prediction tables required)
-       Take 1/2 of the mesiodistal widths of the four lower incisors and adding 10.5mm which is equal to the estimated width of the mandibular canines and premolars in one quadrant
-       1/2 of the mesiodistal widths of the four lower incisors and adding 11mm equals the estimated width of the maxillary canine and premolar in one quadrant

*Neither of these analyses take into account axial inclination of the mandibular anterior teeth, curve of Spee, or differences in race/ethnicity.

Management of Mild Crowding:
-       Early loss of primary tooth most commonly attributed to caries.
-       Premature loss of primary canines: usually a result of large permanent incisors and ectopic eruption, usually accompanied by a lateral shift resulting in a midline discrepancy
-       Fixed lingual arch with soldered spurs can be used to maintain space and prevent tipping of the incisors
-       Early loss of primary molars can cause distal drifting of the primary canine if the loss occurs during the active eruption of the permanent lateral incisors.
-       Ectopically erupted permanent first molars: under the distal surface of the primary second molars causing pathological resorption of the roots, leads to loss of arch length, self correction occurs in 66% (2/3) of cases. In mot instance of self-correction, the distobuccal root is resorbed but the tooth can last until normal exfoliation. When self correction does not occur, brass wire, spring-type deimpactors, or elastic separators are recommended. When the permanent molar is inaccessible, an active appliance like a Halterman is indicated.

Management of Moderate Crowding:
This is usually the result of lack of space or loss of space.
-       Regain space by distalization
-       Easier to regain space in maxilla because of the increased anchorage by the palate
-       Space can be regained for expanded in the mandible with a a lip bumper (if the space loss is bilateral)

Management of Severe Crowding:
-       Cases of 5-9 mm of space deficiency, most will need extraction of permanent teeth to preserve facial esthetics and integrity of supporting soft tissue

Management of Extremely Severe Crowding:
-       Consider serial extraction
-       Guidelines for serial extraction: absence of skeletal discrepancies, large (>10mm) arch-length deficiency, normal overbite, class I malocclusion, commitment on the practitioner's part to finishing the case

Recommended timing of referring patients with crowding to orthodontists for treatment is in the late mixed-dentition stage of development.

Assessment: Good overview of crowding and space preservation. Nice to know while doing hygiene checks when considering the appropriate time to refer to an orthodontist.

Wednesday, January 21, 2015

Posttreatment changes after successful correction of Class II malocclusions with the Twin Bock appliance

Title: Posttreatment changes after successful correction of Class II malocclusions with the Twin Bock appliance
Authors: Mills et al.
Journal: American Journal of Orthodontics and Dentofacial Orthopedics Vol. 118 No.1

Purpose: To determine whether there is any justification for using the Twin Block appliance with skeletal Class II malocclusions.

Background: It is desireable to stimulate mandibular growth as much as possible in young patients with severely retrognathic mandibles in hopes of avoiding more complex treatment after maturity. For this reason, early intervention with orthopedic tx in order to decrease skeletal dysplasia before patients with Class II malocclusions reach their teen years.  Twin Block appliances are simple bite blocks that are designed for full time wear. They achieve rapid functional correction of malocclusion by the transmission of favourable occlusal forces to occlusal inclined planes that cover posterior teeth. The forces of occlusion are used as functional mechanism to correct the malocclusion. By using the Twin Block appliance, the authors intended to ascertain if there was any residual increase in mandibular length remaining at the end of a follow-up period.

Material and Methods: All active tx was carried out during the mixed dentition stage (mean starting age, 9 years 1 month) with a final follow-up for the tx group occurring in the permanent dentition (mean age, 13 years 1 month). The tx group consisted of 28 severe skeletal Class II patients and the comparison group consisted of 28 untreated Class II subjects matched for age, sex, and vertical facial type. Of the 28 control subjects, 24 had 4 year follow-up cephalometric films. The mean age of the controls was 12 years, 11 months at the time of follow-up

Results: During the active treatment phase, the Twin Block group experienced an average increase in mandibular unit length of 6.5mm over a mean of 14 months (annualized rate of change of 5.6mm per year).  In comparison, the control group experienced a 2.3mm increase in mandibular unit length during the 13-month observation period (annualized rate of 21 mm per year). In the post-tx phase, the change in mandibular unit length for the Twin Block group was 6.0mm over a 36-month period (annualized rate of change of 2.0mm per year). The control group experienced an average increase in mandibular unit length of 6.7mm over the post-treatment assessment period that was 34 months long (annualized rate of change of 2.4mm per year).

Conclusion: Although there was a slight reduction in mandibular growth rate after tx, much of the significant increase in mandibular length achieved during the active phase of tx with the Twin Block appliance was still present 3 years later when the subjects had matured into the permanent dentition stage.

Classic 100: Article #38 The effectiveness of protraction face mask therapy: A meta-analysis

Classic 100: Article #38
The effectiveness of protraction face mask therapy: A meta-analysis
Authors: Kim J et. al. 
Am. Journal of Orthodontics and Dentofacial Orthopedics:  Vol 115:6
Resident: Maclin

To increase sample size and provide statistically stronger conclusions regarding the use of protraction face masks for patients with Class III malocclusion

Background Information: 
-Treatment of skeletal Class III malocclusion is most challenging because of unpredictable and potentially unfavorable nature of growth in patients. 
-Traditionally, Class III skeletal relationship was thought to be a result,  of over development or excess growth of the mandible
- However recently, maxillary insufficiency is said to be the most common contributing component of Class III features. 

-Meta-analysis of articles dated 1996 or earlier
-14 articles (11 English + 3 foreign language studies) met the inclusion criteria
- Categories were created based on patient and and appliance use for meta analysis. 

-Common points used in studies included, SNA, BNB, Wits, ANB, mandibular plane angle, palatal plane, upper incisor angle, lower incisor angulation, and A point. 
- It was notes that SNA, Wits, ANB, MPA,  and upper incisor angle increase.
- SNB and lower incisor angulation decrease
- A point moves forward.
-Upper incisor angulation demonstrates greater proclination in the non-expansion groups
-All values of the younger group were larger than the older groups: meaning there was a greater treatment effect in the younger group
-Same degree of improvement was obtained within a shorter period of time with the expansion appliance vs protraction alone: Use of an expansion appliance enhances the protraction effect in terms of time with less dental effect
-More skeletal effect and less dental change with the expansion appliance, while more dental and less skeletal change is produced with the non-expansion appliance
-Protraction face mask therapy is still effective but to a lesser degree in growing patients older than 10 years of age


It is good that the authors saw a lack of information and tried to find an answer in the literature but the authors admit that this was only to help gather the information that we had so that more research could be done. Since this was done 15 years ago, and included no studies more recent that almost 20 years ago it would probably be more beneficial now.  

Anna Abrahamian
January 7, 2014

Article Title: Long-Term Evidence for Favorable Midfacial Growth After Delayed Hard Palate Repair in UCLP Patients.

Author: Hans Friede, DDS, Odont. Dr., et al.

Journal: Classic 100 Articles, #35

Major Topics: Cleft Lip and Palate, Growth and Development

Purpose: To investigate whether delayed hard palate repair resulted in better midfacial growth in the long term than previously achieved with “conventional” surgical methods of palatal closure.
Graber (1949) showed that early aggressive manipulation of palatal structures resulted in poor midfacial development
Opponents argue that delayed closure carries a risk of inadequate speech development
Methods: Long-term cephalometric data from patients withnon-syndromic unilateral cleft lip and palate were available from two Scandinavian cleft centers.  The patients had been treated by different regimens: 1) early repair of the velum (mean: 8 months) then delayed hard palate closure + bone grafting to the alveolar cleft (mean: 8.5 years) versus 2) Hard palate repair with a vomer flap at the same time as the lip operation at about 3 months of age and the posterior palate closed at 22 months (mean) with a pushbacktechnique. Patients were analyzed retrospectively, and one investigator digitized all radiographs. Thirty consecutively treated subjects from each center, with lateralcephalograms taken at three comparable stages between 10 and 16 years of age were reviewed.
Results and ConclusionsPatients whose hard palates were repaired late (early soft palate closure followed by delayed hard palate repair at the stage of mixed dentition) had significantly better midfacial development than patients in whom the hard palate was operated on early with avomer flap, and then during the second year of life, the soft palate was repaired with a push-back procedure.  As the growth advantage in the delayed hard palate repair group was accomplished without impeding long-term speech development, the delayed repair regimen proved to be a good alternative in surgical treatment of patients with unilateral cleft lip and palate.
Discussion/Assessment: This was an interesting article – it would be interesting to see a study about QOL variables that are affected (i.e., nutrition and overall growth) in children with delayed repairs.

Orthodontists’ Perceptions of the Impact of Phase 1 Treatment for Class II Malocclusion on Phase 2 Needs

Article Title: Orthodontists’ Perceptions of the Impact of Phase 1 Treatment for Class II Malocclusion on Phase 2 Needs

Authors: GJ King, TT Wheeler, SP McGorray, LS Aiosa, RM Bloom, MG Taylor

Journal: Journal of Dental Research 78(11): 1745-1753, November, 1999

Main Purpose: To examine how orthodontists, blinded to treatment approach, perceive the impact of phase 1 treatment on phase 2 needs.

Background: Almost 23% of malocclusions in children aged 10-12 are Class II. The most appropriate timing for the treatment of Class II malocclusions is controversial. Some clinicians advocate starting a first phase in the mixed dentition, followed by a phase 2 in the permanent dentition. Others see no clear advantage to that approach and recommend that the entire treatment be done in the late mixed or early permanent dentition.

·      242 class II subjects aged 10-15 were included in the randomized clinical trial.
·      For each subject, video orthodontic records, a questionnaire, a fact sheet, and a cephalometric tracing were sent to 5 randomly selected reviewing orthodontists blinded to the subject group and study purpose.
·      Reviewing orthodontists were asked to assess treatment need, general approach, need for extractions, priority, difficulty, and determinants.

Key Points:
·      In the study: 95% of orthodontists agreed on treatment need, 84% agreed on treatment approach, 80% agreed on extraction need.
·      Previously treated patients were judged as less difficult and to have a lower treatment priority.
·      The most highly ranked problems ranked by orthodontists for treating class II patients are overbite, dental class II relationship, overjet, skeletal, and crowding.
·      The most common reasons for not selecting treatment are no need for treatment (45.7%), no cooperation expected (24.3%), and too early to begin treatment (15.7%).
·      Orthodontists do not perceive phase 1 treatment as preventing the need for a second phase or as offering any particular advantage with respect to preventing the need for extractions or other skeletal treatments in the second phase
·      Orthodontists do view early class II treatment as an effective means of reducing the difficulty and priority for phase 2
·      Assessment of need changes over time because of changes in criteria and approaches.
·      There was more of a need for extraction in the high mandibular plane angle cases.
-       Due to clinicians belief that this may enhance the ability to control the anterior bite depth and rotate the mandibular plane counterclockwise.
·      Dental Class II and skeletal relationship were ranked significantly higher in the control subjects than for those receiving early treatment.
-       This suggests that Phase I treatments made a clinically detectable difference in Class II severity.