Wednesday, July 29, 2015

Guideline for management of traumatic dental injuries: Injuries in primary dentition

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:             Leslie M Slowikowski                                                                        Date: 07/29/2015
Article Title: Guideline for management of traumatic dental injuries: Injuries in primary dentition
Author(s): International Association of Dental Traumatology
Journal: AAPD Reference Manual
Date: Endorsed by AAPD in 2013
Major Topic: Management of Traumatic Dental Injuries – Primary Dentition
Type of Article: Recommendations created literature review by task force
Main Purpose: Provided guidelines for management of trauma in primary dentition
Key Points/Summary:  Trauma – oral region 5% of all injuries that people seek treatment for.  Age group 0-6 y/o ranked the second most common injury covering 18% of all somatic injuries. 

Special considerations:  Young child is difficult to examine and treat due to lack of cooperation.  There are varying conditions in different countries concerning economic and social aspects as well as treatment philosophies.  Important to keep in mind there is close relationship between apex of the root of the injured tooth and the developing permanent tooth.  White or yellow-brown discoloration of crown and hypoplasia of permanent incisor are common with intrusion and avulsion of primary teeth.  Do not reimplant an avulsed primary incisor.  Consideration must be made for child’s maturity and ability to cope with emergency situation also shedding time of tooth and occlusion.  Trauma is usually repeated so consider the shorten survival time of the tooth.  After diagnosis – treatment planning id done for the child’s benefit between the provider and the parents.

Clinical exam:  Complete clinical exam and always consider child abuse for children under the age of 5. 

Radiographic exam:  Essential to establish the extent of injury.  Confirming diagnosis, consider minimizing the risk of radiation to the child.  Occlusal view, extra-oral lateral, 90 degree horizontal view. 

Splinting:  Alveolar bone fracture and possibly for intra-alveolar root fractures

Use of antibiotics:  No evidence of the use of systemic antibiotics in the management of luxation injuries.  Depends on accompanied soft tissue and other associated injuries that require significant surgical intervention and/or medical status that may warrant antibiotic coverage.  Special medical condition consult pediatrician.

Sensibility and percussion test – primary teeth inconsistent results- not reliable.

Crown discoloration:  Common complication after luxation.  Discoloration may fade or persisting dark discoloration may remain asymptomatic clinically and radiographically, or develop apical periodontitis.  Unless  associated infection exists, RCT is not indicated. 

Pulp canal obliteration: Common in luxation – 35-50%, indicated ongoing pulp vitality – yellowish her can be noted.

Parent instructions:  Good healing depends on good oral hygiene.  Supervising potentially hazardous activities.  Brushing with soft brush and using 0.1% chlorhexidine gluconate topically on the affected area with cotton swabs 2x/day for 1 week.  Soft diet for 10 days and restriction in the use of intra-oral pacifier.  Parent or caregiver should be advised of potential complications – swelling, increased mobility, abscess and should bring patient in for treatment if any of these arise.  Documentation that the caregiver/parents have been informed of potential complication in the development of permanent teeth especially following intrusion, avulsion, and alveolar fracture injures.  

Assessment of Article:  Level of Evidence/Comments: III

Treatment on Plaque-induced Gingivitis, Chronic Periodontitis, and Other Clinic Conditions

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:             Leslie M Slowikowski                                                                        Date: 07/29/2015
Article Title: Treatment on Plaque-induced Gingivitis, Chronic Periodontitis, and Other Clinic Conditions
Author(s): American Academy of Periodontology – Research, Science, and Therapy Committee / Endorsed by the AAPD
Journal: AAPD Reference Manual
Date: 2004
Major Topic: Plaque Induced Gingivitis, Periodontitis, and other Clinical Condidtions
Type of Article: Recommendations created from literature review
Main Purpose: Provided treatment guidelines for Plaque-Induced Gingivitis, Chronic Periodontitis, and other Clinical conditions
Key Points/Summary: 
Gingivitis – primary etiology is bacterial plaque, inflammation of the gingival, reversible disease.  Supportive periodontal maintenance that included personal and professional care is important in preventing re-initiation of inflammation.

Periodontitis – inflammation of the gingival and adjacent attachment apparatus, characterized by loss of connective tissue attachment and alveolar bone.  Therapeutic approaches are in 2 categories: 1) anti-infective treatment, halt the progression of periodontal attachment loss by removing etiologic factors 2) regenerative therapy, which includes anti-infective treatment and is intended to restore structures destroyed by disease

Plaque induced gingivitis:  Reduce oral bacteria.  Improved personal plaque control with periodic professional reinforcements.  Removal of calculus and other associated local factors (defective restorations).  May need scaling and root planning to reduce subgingival bacteria below a threshold level.  One of the three medicament with the ADA seal for contonl of gingivitis.  Active ingredients are 1) thymol, menthol, eucalyptol and methylsalicylate.  2) Chlorhexidine digluconate  3)Triclosan.  Supragingival plaque is affected with medicaments with flushing out of the subgingival bacteria.  All ways consider systemic factors (diabetes, pregnancy) and once those issues resolve so will the gingivitis with proper plaque control.

Acute Periodontal disease:
NUG: personal plaque control with professional debridement, if lymphadenopathy or fever accompanies oral symptoms, administration of systemic antibiotic may be indicated.
NUP: debridement which may be combined with irrigation with antiseptics (povidone iodine), antimicrobial mouth rinses (chlorhexidine) and administration of systemic antibiotics.  In HIV positive patient is may not appear with ulcerative lesions but with severe loss of periodontal attachment called linear gingival erythema – does not respond to conventional scaling, root planning, and plaque control.  Antibiotic therapy should be used in HIV-positive patient due to possibility of inducting opportunistic infections. 
Primary herpetic gingivitis – self limiting 7-10 days, acyclovir is appropriate for the immunocompromised patient

Gingival Enlargement– chronic gingival inflammation; patient with genetic or drug-related systemic factors (anticonvulsants, cyclosporine, and calcium channel blocking drugs).   Phenytoin- gingival overgrowth minimized with appropriate personal oral hygiene.  Root debridement is ineffective.  Recontouring is suggested or consulting physician about changing medications.  IF medication can not be changed then continued surgical and on-surgical interventions will be needed.

Chronic Periodontitis: 
·      Scaling and root planning - to reduce amount and type of subgingial bacteria.  Personal oral hygiene needs improvement.  Reassessment 6-8 weeks post SRP procedure important for identification of any residual spots.  Re-enforce OH.  Also take into consideration patient ability to properly clean (deep probing depths, root concavities, furcations)
·      Pharmacological therapy: Systemic drug administrations – an appropriate adjunctive for patients with multiple sites unresponsive to mechanical debridement, acute infections, medically compromised patients, presence of tissue-invasive organism and ongoing disease progression.  Should identify the pathogenic organism and complete a sensitivity test.  NSAIDS and subantimicrobial dose doxycycline.  Always consider potential benefits and side effects of systemic pharmacological therapy. 
·      Local delivery:  Acetate fiber with tetracycline, gelatin chip with chlorhexidine and minocycline as adjuncts.  Have to consider possible allergic reaction, inability to disrupt biofilms and failure to remove calculus.  Discretion of the provider – you can reference a paper on “the Role of Controlled Drug Delivery for Periodontitis.”
·      Surgical Therapy:  1) provide better access for removal of etiologic factors 2) reduce deep probing depths and 3) regenerate or reconstruct lost periodontal tissues. 
·      Regenerative surgical therapy:  use of adjunctive surgical technique devices and materials.  Chemical substance that modify the root surface and promote new attachment, bond grafting, guided tissue regeneration, biologically engineered tissue inductive proteins. These may not be effective if patient has other issue such as diabetic or smoking which minimize efforts 

Occlusal management:  Excessive occlusal forces can contribute to increased tooth mobility and other adverse effects on the periodontium.  Occlusal equilibrations.  Depend on clinical judgement.

Monitoring periodontal status and appropriate maintenance should be part of managing a long term perioodontal problem.

Assessment of Article:  Level of Evidence/Comments: III

Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:                                                                                                        Date:

Article Title: Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection
Author(s): Clinical Affairs Committee
Journal: AAPD Reference Manual
Date:Last Revised 2014
Major Topic: SBE Antibiotic prophylaxis
Type of Article: Guideline
Main Purpose: To intend help practitioners make decisions regarding antibiotic prophylaxis for dental patients at risk.
Key Points/Summary:

Bacteremia, bacteria in the blood, is anticipated following dental procedures. Infective endocarditis is an uncommon but life-threatening complication resulting from bacteremia. The incidence of IE ranges from 5.0 to 7.9 per 100,000 persons a year. Viridians group streptococci, Staphylococcus aureus, enterococcus, pseudomonas, serratia, and candida are some of the microorganisms implicated with IE. The vast majority of IE cases caused by oral microflora can result from bacteremia associated with routine daily activities such as tooth-brushing, flossing, chewing. Antibiotic prophylaxis is recommended with certain dental procedure, however, although the decision to use antibiotic prophylaxis should be made on an individual basis. In 2007, the American Heart Association released its newly revised guideline for the prevention of IE and reducing the risk for producing resistant strains of bacteria. Major changes in the revision include:
·      Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective.
·      Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. These dental procedures involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
·      Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis.

The AHA recommends antibiotic prophylaxis only for those whose underlying conditions are associated with the highest risk of adverse outcome: prosthetic heart valves or prosthetic material used for cardiac valve repair, previous history of IE, unrepaired or incompletely repaired cyanotic congenital heart disease including palliative shunts and conduits, completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, and repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop cardiac valvulopathy such as valve regurgitation.

Patients with compromised immunity may also not be able to tolerate transient bacteremia following dental procedures. This category includes: Immunosuppressed patients (HIV, SCIDs, neutropenia, cancer chemo, hematopoietic stem cell transplantation), head and neck radiotherapy, autoimmune disease, sickle cell, asplenism, chronic steroid usage, diabetes, bisphosphonate therapy.

The AHA recommends that antibiotic prophylaxis be given for nonvalvular devices (indewelling vascular catheters) and cardiovascular implantable electronic devices only at their placement  but not for dental procedures. On the other hand, ventriculoatrial (VA), ventriculocardiac (VC), or ventriculovenus (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections due to their vascular access and prophylaxis is recommended.

For patients with prosthetic joints, antibiotic prophylaxis has not shown a significant reduction in the risk of developing joint infections subsequent to dental procedures. Therefore, antibiotic prophylaxis is not indicated for dental patients with pins, plates, screws, or other hardware that is not within a synovial joint nor is it indicated routinely for most dental patient with total joint replacements.

Consultation with the child’s physician may be necessary for management of at-risk patients as well as patients with other ilanted devices.
Assessment of Article:  Level of Evidence/Comments: Level 1


Periodontal Diseases of Children and Adolescents

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:                                                                                                        Date:

Article Title: Periodontal Diseases of Children and Adolescents
Author(s): American Academy of Periodontology
Journal: AAPD Guidelines
Date: Last Endorsed 2004
Major Topic: Periodontal Disease
Type of Article: Guideline (systematic review)
Main Purpose: Classification of periodontal diseases
Key Points/Summary:
Periodontal diseases that can affect young individuals include: 1.) Dental plaque induced gingival disease 2.) chronic periodontitis 3.) Aggressive periodontits 4.) periodontitis as manifestation of systemic diseases 5.) necrotizing periodontal diseases

Dental Plaque Induced Gingival Disease
·      Gingivitis characterized by the presence of inflammation without detectable loss of bone or clinical attachment is common. Bacteria commonly associated in gingivitis in children include: Actinomyces sp, Capnocytophaga sp, Leptotrichia sp, and Selenomonas sp. It has been found that changes in hormonal levels during puberty can affect the gingival inflammatory response to dental plaque as well as changes in insulin in diabetic patients; both result in increased inflammatory response.

Aggressive periodontitis, chronic periodontitis, and periodontitis as a manifestation of systemic diseases
·      Primary features of aggressive periodontitis include history of rapid attachment and bone loss with familial aggregation; secondary feature include phagocyte abnormalities and hyperresponsive macrophage phenotype
o   Localized aggressive periodontitis patients have interproximal attachment loss on at least two permanent first molars and incisors, with attachment loss on no more than two teeth. It occurs in children and adolescents without clinical evidence of systemic disease and is characterized by the severe loss of alveolar bone around permanent teeth. Bacteria of etiologic importance include Actinobacillus actinomycetecomitans and Eubacterium sp. Also, a variety of functional defects at the cellular-molecular level have been reported in patients with localized aggressive periodontitis.
o   Generalized aggressive periodontitis involves interproximal attachment loss including at least three teeth that are not first molars and incisors. It is considered to be a disease of adolescents and young adults, but can begin at any age. Associated bacteria include P. gingivalis and Treponema denticola. Functional defects at the cellular-molecular level have also been reported (ie. Suppressed chemotaxis of neutrophils).
o   Successful treatment of aggressive periodontitis depends on early diagnosis, directing therapy against the infecting microorganisms and providing an environment for healing. For localized aggressive periodontal treatment, most authors recommend a combination of surgical or non-surgical root-debridement in conjunction with antimicrobial therapy (ie. Tetracyclines prescbribed sequentially with metronidazole). On the other hand, generalized aggressive periodontitis does not often respond well to conventional mechanical therapy or to antibiotics
·      Chronic periodontitis is most prevalent in adults, but can occur in children and adolescents. It can be localized or generalized and is characterized by a slow to moderate rate of progression that may include periods of rapid destruction .
·      Periodontitis associated with systemic diseases occurs in children and adolescents: Papillon-Lefevre syndrome, cyclic neutropenia, aganulocytosis, Down Syndrome, hypophosphatasia, and leukocyte adherence deficiency. Defects in neutrophil and immune cell function associated with these diseases plays an important role in increased susceptibility to periodontitis. Diabetes is also a significant modifier, as diabetic patients may have over periodontitis often localized to the first molars and incisors.

Necrotizing Periodontal Diseases
·      Seen with greater frequency in certain populations of children and adolescents from developing areas of Africa, Asia, and South America. The two most significant findings used in the diagnosis of NPD are the presence of interproximal necrosis and ulceration and the rapid onset of gingival pain. Bacteria associated are spirochetes and P. intermedia. Factors that predispose children to NPD include viral infections, malnutrition, emotional stress, lack of sleep, and a variety of systemic diseases. Treatment involves mechanical debridement, oral hygiene instruction, and careful follow-up

Conclusion: Early diagnosis ensures the greatest chance for successful treatment; it is important that children receive a periodontal examination as part of their routine dental visit.

Assessment of Article:  Level of Evidence/Comments: Level 1