Wednesday, November 18, 2015

Oral Conditions in Children with Cerebral Palsy

Resident’s Name: Semantha Charles      Date: 11/17/2015

Article Title:  Oral Conditions in Children with Cerebral Palsy
Journal:  Journal of Dentistry for Children
Author: Maria Teresa Botti Rodrigues dos Santos, DOSe, PhD Danilo Masiero, MD, PhD
Neil Ferreira Novo, DOSe, PhD Maria Regina Lorenzetti Simionato, DOSe, PhD
Date: 2003
Purpose: to investigate dental caries, plaque index, time of eruption, malocclusion, bruxism and motor oral skills in a group of 62 CP children.

Key Points/Summary:

Cerebral palsy (CP) belongs to the group of the most common and severe disabilities of childhood, characterize by a set of non-progressive motor disorder of posture and movement due to a lesion in the developing brain.
The rate of CP has risen in spite of falling perinatal and neonatal mortality rates, a rise that is even more pronounced when the mildest and least reliably ascertained cases were excluded.

Dental Findings in Patient with CP when compared to normal children.

A significantly higher DMFS index for CP children with permanent dentition of both sexes when compared to normal children.
A significantly higher plaque index was also observed in the study group.
A high tendency to delayed eruption of permanent molars and significantly higher percentages of malocclusion and bruxism were observed in the study group with permanent dentition. Residual food and mouth breathing have been frequently found in CP children.

Conclusions: Earlier preventive measures for CP patients are required because they are a high-risk group for dental caries.

Caries Risk Indicators in Children with Type I Diabetes Mellitus in Relation to Metabolic Control

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                         Date: 11/18/2015

Article Title: Caries Risk Indicators in Children with Type 1 Diabetes Mellitus in Relation to Metabolic Control
Author(s): El-Tekeya, M; Tantawi M, Fetouh H
Journal: Pediatric Dentistry
Date: 11,12/2012
Major Topic: Caries risk in diabetic children
Main Purpose: Determine caries risk in relation to metabolic control in diabetics.

Key Points/Summary:
- Purpose: The purpose of this study was to investigate the interaction of caries risk indicators and metabolic control in children with type 1 diabetes mellitus.
-Methods: The study included 50 children with type 1 DM and 50 healthy controls, all 6 to 9 years old. Diabetic children were classified into 3 groups: well, fairly, and poorly controlled based on glycosilated hemoglobin level. Personal, family data, medical and dental history were collected. Children were examined for caries experience, plaque, and gingival condition. Saliva samples were obtained for culturing mutans streptococci, lactobacilli, and Candida, and colony forming units were counted.
-Results: No significant differences existed between all groups regarding caries experience or mean log count of micro-organisms. Diabetic children differed significantly from healthy children in parental occupation and education, dental visits, oral hygiene, and plaque and gingival indices, whereas no differences were observed among children with different levels of metabolic control regarding these factors. Regression analysis identified mutans streptococci as a significant variable affecting caries experience in diabetic children.
-Conclusions: Regarding the interaction of caries risk indicators and metabolic control on caries experience in diabetic children, the only variable that showed a significant effect was mutans streptococci.

Take Home
- Regarding the interaction of caries risk indicators and metabolic control on caries experience in diabetic children, the only variable that showed a significant effect was mutans streptococci.

Other thoughts:
-Twetman et al. found that caries-active children displayed higher HbA1c levels vs caries-inactive diabetics. Similarly, Karjalainen et al. deduced that poorly controlled subjects had significantly higher caries experience than well or moderately controlled diabetics. Twetman et al. also documented a statistically significant positive relationship between caries risk and metabolic control among 8- to 16-year-old type 1 diabetics, with a 7-fold increased risk of metabolic control after 3 years in those assessed with high caries risk at onset. Hence, they concluded that an increased caries risk at diagnosis provided prognostic information on the level of metabolic control 3 years later.
-Diabetic children reported much lower levels of oral hygiene practices and dental visiting rates than healthy children. This lower level may be explained by the demanding care needed to manage diabetes, which is a potentially life-threatening disease that leaves little time for oral health care practices. Alternatively, these better oral practices observed in the healthy children may be associated with the better education of their parents, which is more likely to promote awareness of oral health awareness.
This is against what you would think, with less recare and lower levels of oral hygiene, you would expect higher caries risk to be concluded. Patient selection may not have been best in order to determine risk factors. Decreased immune function may explain increased risk of periodontal disease, but does not automatically increase caries risk.

Special needs

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Mark Dawoud, DMD                                                Date: 11/18/15
Article Title:
·       Special Health Care Needs pg 16
·       Medically Necessary Care pg. 18
·       Management of Dental patients with Special Health Care Needs pg. 161
Authors: Council on Clinical Affairs.
Journal: AAPD Reference Manual
Date: 2012, 2015
Major Topic: Special Health Care needs and management.
Type of Article: Guidelines
Main Purpose: The purpose is to make recommendations regarding management of dental patients with special health care needs.

·       Medically necessary care (MNC) is the reasonable and essential diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and follow-up care as determined by qualified health care providers in treating any condition, disease, injury, or congenital or developmental malformation to promote optimal health, growth, and development.
·       Health care for individuals with special needs requires specialized knowledge acquired by additional training, as well as increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine.
·       The need for increased dentist and team time as well as customized services should be documented so the office staff is prepared to accommodate the patient’s unique circumstances at each subsequent visit.
·       If treatment of an adult patient with SCHN is out of the scope of a pediatric dentist, at an agreed upon time, the patient, parent and pediatric dentist should transition the patient to a dentist knowledgeable in specific health care needs.
·       Developmentally appropriate communication is critical.
·       Before a treatment plan could be developed and presented to the patient and/or caregiver, information regarding medical, physical, psychological, social, and dental histories must be gathered and clinical examination and any additional diagnostic procedures completed.
·       All patients must sign informed consent or have someone present who can legally provide the service.
·       Caregivers may provide assistance. Protective stabilization may be used as well as sedation or GA.
·       Dentists should be familiar with community-based resources for patients with SHCN and encourage such assistance when appropriate. 
Level of Evidence/Comments: Providers should be knowledgeable and capable of working with caregivers and other providers for coordinated care.

Internal Validity: III;

Clinical Genetics for the Dental Practitioner

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Date: 
Article Title: Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Date: 
Article Title: Clinical Genetics for the Dental Practitioner
Author(s): Hartsfield, Bixler
Journal: Dentistry For the Child and Adolescent
Date: 2011
Major Topic: Genetics
Type of Article: Chapter 
Main Purpose: Review of Genetic Principles
Key Points/Summary:
  • Cell differentiation and developmental biology
  • Chromosomes  
  • Hereditary traits in families
  • Developmental Biology of Enamel: 
    • o Three major types of inherited enamel defects: hypoplasia, hypocalcification, and hypomaturation
    • o One characteristic of inherited dental defects is that both dentitions are affected; occasionally, the defect is expressed differently in the two dentitions
    • Autosomal Dominant Inheritance
    • Autosomal Recessive Inheritance
    • X-linked or Sex-Linked Inheritance

Level of Evidence: Level 1:I

Guideline on Record Keeping and Informed Consent

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:  John Kiang                                                                                         Date: 11/18/15
Article Title: Guideline on Record Keeping and Informed Consent
Author(s):  Council on Clinical Affairs
Journal: AAPD Reference Manual
Date: 14/15
Major Topic: Record Keeping
Type of Article:
Main Purpose: Patient record keeping and informed consent protocol/guidelines/recommendations
Key Points/Summary:

Record Keeping
·      Record should be authentic, accurate, legible and objective. Each patient should have an individual record. Chart entries should contain the initials/name of the individual making a note. Problem focused note is best
·      Initial Patient Record: Patients name, DOB, address, phone #, significant medical hx, chief complaint
·      Components of Patient Record: MdHx, DentHx, Clinical assessment, Diagnosis, Tx reccs. Progress note, HIPAA; When applicable include: Radiographic assess, caries risk, informed consent, sedation/anesthesia records, trauma records, orthodontic records, consults, labs, test results,
·      Medical Hx: up to date is essential to make the proper diagnosis; Md conditions/illnesses, name and telephone # of primary care doc or specialists, hospitilizations/surgeries, anesthetic experience, current meds, allergies, immunization status, review of systems, family hx, social hx
·      Medical update should be obtained at every recall visit
·      Dental Hx: chief complaint, previous dental experience, date of visit/radiographs, oral hygiene practices, fluoride exposure/hx, dietary habits, oral habits, sports activities, previous orafacial trauma, TMJ hx, Family hx of caries, social development
·      Comprehensive Clinical Exam: General growth assess, pain assess, EOE soft tissue, TMJ, IOE soft tissue, OH, Assess of occlusion, IOE hard tissue, Radiographic assess, caries risk, behavior
·      Progress Note: Date of visit, reason for visit/cc, radiographic exposure, tx rendered + any anesthetic agents, post-op instructions; in addition: changes in md hx, adult with child, verification of compliance with preop instructions, reference to supplemental documents, patient behavior guidance, anticipated followup visit.

Informed Consent
·      Is the process of providing the patient, or in the case of minor or incompetent adult, the parent relevant information regarding diagnosis and treatment needs so that an educated decision regarding tx can be made by the patient/parent/guardian.
·      Depending on the state, it can be oral discussion which should be documented in the chart, or written consent.
·      Informed Consent should include: Legal name, DOB of patient, legal name of guardian/relationship, patients diagnosis, nature and purpose of tx, potential benefits and risks associated, professionally recognized or EBD alternative to tx, including no tx, place for parent to indicate that all questions have been asked/answered, places for signatures of parent/guardian, dentist, and office staff.

Policy on Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:John Kiang                                                                                           Date: 11/18/15
Article Title: Policy on Management of Patients with Cleft Lip/Palate and Other Craniofacial Anomalies
Author(s): Clinical Affairs Committee
Journal: AAPD Guidelines
Date: Revised 2012
Major Topic: CL/P Management
Type of Article: Guidline  
Main Purpose:  Discuss the management and care of treating patients with craniofacial anomalies
Key Points/Summary:

·      Care should be comprehensive, coordinated, culturally sensitive, specific needs, and readily accessible
·      Best approach is by interdisciplinary team of specialists: medical, surgical, dental, allied health fields
·      Optimal time of eval is within the first few weeks of life
·      Radiographs: ceph, pano etc should be used as indicated to evaluate and monitor dental and facial growth and development
·      Diagnostic records should be taken when appropriate to assess patients risk for developing malocclusion
·      Before primary dentition has completed eruption, the skeletal and dental components should be evaluated to determine if a malocclusion is present or developing
·      Ortho management may be performed in the primary, mixed or perm dentition.
·      Continuous ortho from the early mixed dentition to perm dentition should be avoided. Ortho retention may be extended into adulthood
·      Ortho + surgical correction may be needed for facial deformity
·      Congenitally missing teeth may be replaced with removable appliance, fixed restorative bridge work, or implants
·      Patients should be closely monitored for perio disease
·      Prosthetic obturation of palatal fistulae may be necessary in some patients
·      A prosthetic speech device may be used to treat velopharyngeal inadequacy in some patients.

Tuesday, November 17, 2015

Hemangiomas in children

Department of Pediatric Dentistry

Lutheran Medical Center

Resident’s Name: John Diune                                                                        Date: 11/18/2015
Article Title: Hemangiomas in children
Author(s): Drolet, B. A., Esterly, N. B. and Frieden, I. J
Journal: New England Journal of Medicine
Date: July 15, 1999
Major Topic: Special care for special patients
Type of Article:
Main Purpose: Discussion of Hemangiomas, pathogenesis, clinical manifestations, complications, management
Key Points/Summary:
  • Most common soft tissue tumor of infancy (5%-10% of 1 year olds)
  • Definitions:
    • Vasculogenesis: process by which precursors of endothelial cells give rise to blood vessels
    • Angiogenesis: development of new vessels from existing vasculature
  • During proliferative phase, hemangiomas are made up of densely packed endothelial cells forming small capillaries
    • Cellular markers of angiogenesis can be identified using immunochemical analysis (proliferating-cell nuclear antigen, type IV collagenase, basic fibroblastic growth factor, vascular endothelial growth factor, urokinase, E-slectin)
    • Urinary levels of fibroblastic growth factor elevated in infants; means to monitor treatment efficacy
  • Developmental-field defects at 8-10wks of gestational age may account for presence of anomalous arteries
    • Risk of hemangioma 10X higher in children of parents who had chorionic-villus sampling
  • Differs from most other tumors: has phase of rapid proliferation followed by spontaneous involution
  • Clinical manifestations:
    • Newborn: pale macule with thread-like telangiectases
    • As tumor proliferates: bright red, slightly elevated, noncompressible plaque
    • Deeper in skin: soft, warm masses with slightly bluish color
    • Female infants 3x as likely than male infants; 20% of affected have multiple lesions
    • Superficial hemangiomas reach full size by ~6-8mths; deeper ones may proliferate to ~12-14mth
    • 20%-40% leave residual changes of the skin; large superficial hemangiomas of the face leave can leave disfiguring scars
  • Complications
    • Ulceration – most frequent; carries risk of infection, hemorrhage, and scarring
      • Usually due to ischemia and necrosis
      • In cases of hemorrhage, direct pressure usually sufficient
      • Superinfection may lead to cellulitis, osteomyelitis, or septicemia
    • Kasabach-Merritt Phenomenon – complication of rapidly enlarging vascular lesions
      • Not typical – instead have kaposiform hemangioendotheliomas (tufted angiomas) with high mortality rate
    • Regionally Important Lesions
      • Multiple hemangiomas and large facial hemangiomas may be associated with visceral hemangiomas
        • Visceral hemangiomas (particularly of liver) higher mortality rate (40%-80%) – need monitoring
      • Slowly proliferating legions may pose threat if compromise vital structure (periorbital region, area involving ear may also affect speech development, airway)
    • Dysmorphic features – 2 particular conditions due to hemangiomas
      • Extensive hemangiomas of the neck and face may be associated with PHACES syndrome (Posterior fossa malformations, Hemangiomas of the cervicofacial region, Arterial anomalies, Cardiac anomalies, Eye anomalies, Sternal or abdominal clefting or ectopic cordis); predominance Girls(9):(1)Boys
      • Hemangiomas of the lumbosacral region may be marker for occult spinal malformations and anomalies of anorectal and urogenital regions – imaging of spine indicated
  • Treatment/Management
    • 1940’s-50’s – Irradiation used; decried by experts due to aggressive treatment to treat self-limiting tumors
    • But other options available: lasers, corticosteroids systemically or directly into lesion, Interferon alpha, and prospect of new inhibitors
    • Whether to treat depends on possible complications due to hemangioma that may be life threatening or controversial in cases of hemangiomas that may cause permanent disfigurement
    • Systemic corticosteroids are mainstay in treatment of hemangiomas (2-3mg/kg of prednisolone or prednisone) – results in shrinkage (1/3 smaller, 1/3 reduced growth, 1/3 no affect)
      • Side effects include: irritability, GI upset, immunosuppression, HTN, growth retradation
    • Corticosteroids injected directly into lesion (triamcinolone 3-5mg/kg per tx session)
    • Recombinent interferon Alpha – inhibitor of angiogenesis; for failed treatment using steroids
      • Side effects include: irritability, neutropenia, and abnormalities of liver enzymes; especially worrisome spastic diplegia (potentially irreversible, affects 20% of patients)
    • Lasers – optimum delivery systems not yet found
    • Cryotherapy – concerns with scarring (but used widely in Europe and South America
    • Bleomycin injected directly into lesion
    • Surgical excision early or to repair residual cosmetic deformities later on
Assessment of Article:  Level of Evidence/Comments:


The American Academy of Developmental Medicine and Dentistry: Eliminating health disparities for individuals with mental retardation and other developmental disabilities.

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Amir Yavari                                                                                   Date: 11/18/2015

Article Title:  
 The American Academy of Developmental Medicine and Dentistry: Eliminating health disparities for individuals with mental retardation and other developmental disabilities.
Fenton, S., et al.
Journal:  Journal of Dental Education
Date: 2003
Major Topic:
How to solve the disparities and unmet health needs encountered by persons with mental retardation and other developmental disabilities
Type of Article:
Review of articles and opinion of expert
Main Purpose:
Show different ways to provide a better dental and medical care for people with mental retardation and other developmental disabilities

Key Points/Summary:
Significant disparities and unmet health needs encountered by persons with mental retardation and other developmental disabilities (MR/DD). Factors contributing to these disparities include deinstitutionalization, increased survival of individuals with MR/DD, lack of appropriately trained providers, and inadequate financing of dental services.
To address these problems, a group of academically oriented dentists and physicians formed the American Academy of Developmental Medicine and Dentistry (AADMD). The mission of the AADMD is to improve the quality of health services provided to persons with MR/DD by improving dental and medical school-based training of dentists and enhancing clinically relevant research.
- Deinstitutionalization and an increasing life expectancy have created a crisis in access to health care for adults with MR/DD. The severity of observed disease in this population drives the need for action. One of the first steps necessary to improve training is the recognition of the critical importance of dentist/physician collaboration in the care of patients with MR/DD. It is important for physicians and dentists to view each other as colleagues with a common purpose and as reciprocal sources of professional strength and support.
- Substantial progress toward eliminating health disparities for persons with MR/DD will also require that all medical and dental schools incorporate appropriate curriculum at the undergraduate level. In addition, more fellowships in developmental dentistry and medicine must be implemented and evaluated. The desired goal is to extend accepted, high standards of health care to individuals with MR/DD wherever they reside.
- Eliminating oral health disparities for this population also requires further development of an evidence base for clinical care, including important oral systemic interactions. The timing is ripe for such changes, with the recent announcement of a concept clearance for Clinical Research to Improve Oral Health of Special Needs Populations and the Elderly by the National Institute for Dental and Craniofacial Research (NIDCR). Concepts approved by the NIDCR represent early planning stages for initiatives.
- The establishment of the AADMD represents, in many ways, a first, critical step towards accomplishing many of these goals. The AADMD principals will help in whatever ways possible to provide support, content, and expertise to similar efforts wherever they are occurring and call upon academicians, clinicians, and researchers to join them in this effort.

- AADMD would address the unmet health needs encountered by persons with special needs
-  Deinstitutionalization  à These patients need to be treated with a good communication between dentist and MDà Communication
- Medical and dental schools should incorporate appropriate curriculum at the undergraduate level
- Prevention as well as represent early planning stages for initiatives
- AADMD: connects academicians, clinicians, and researchers

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