Tuesday, June 6, 2017

Enamel defects on permanent successors following luxation injuries to primary teeth and carers’ experiences


Department of Pediatric Dentistry

Lutheran Medical Center
        
Resident’s Name: John Diune                                                                                    Date: 6/6/2017

Article Title: Enamel defects on permanent successors following luxation injuries to primary teeth and carers’ experiences
Author(s): AnneSkaare, Anne-Lise Maseng Aas, Nina Wang
Journal: International Journal of Paediatric Dentistry
Date: 2014
Major Topic: Trauma
Type of Article: current and retrospective investigation of trauma
Main Purpose: study frequency of enamel defects in permanent successors following luxation injuries and also report child’s carers’ experiences.
1)      Key Points: (2 lines Max): Minor luxation injuries and indirect trauma may cause enamel defects in permanent successors
2)      Younger age at injury, severity, and number of injured teeth negatively affect patient and carer
 
From literature:
-          Most common sequela to permanent successor is discoloration of enamel
-          Intrusion > avulsion – to cause mineralization disturbances
o   Lateral luxation and subluxation cause defects less frequently (10-30%)
 
170 8-15yo’s suffering from luxation injuries in 2003 were reexamined in 2010
-          Benefit of this study is nearly all trauma registered due to being part of Public Dental Service system (not only emergency room of a hospital or trauma center)
300 total permanent successors examined clinically
-          Enamel defects were registered in 130 successor teeth
o   22% due to trauma
o   21% due to other etiological factors (MIH, dental fluorosis, idiopathic)
-          Breakdown of enamel defects due to types of trauma:
o   Concussion 8%
o   Subluxation 18%
o   Lateral luxation 41%
o   Intrusion 38%
o   Avulsion 47%
 
Carers’ experience obtained via analysis of questionnaire (2010)
-          8 children developed dental fear (7 were younger than 3.5 years and had removal of injured teeth)
-          Breakdown of responses:
o   53% remembered trauma as stressful
§  90% psychological concern
§  7% time-consuming
§  3% psychological and time-consuming
o   42% did not remember trauma as stressful at all
o   5% did not recall the trauma
 
Discussion:
-          Most common enamel defect observed is small demarcated opacities
o   May be due to even minor disturbance of the surrounding soft or hard tissue
-          Indirect trauma can occur during very early phase of development at onset of calcification
o   Follicle is particularly susceptible to transmission of inflammatory mediators
o   Also, surrounding bone is less calcified and not protect developing tooth germ as well
 
Remarks:
 
 
Assessment of Article:  Level of Evidence/Comments:

 

Consumer products and activities associated with dental injuries to children treated in United States emergency departments

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Amir Yavari                                                                                   Date: 06/06/2017

Article Title:  
Consumer products and activities associated with dental injuries to children treated in United States emergency departments, 1990-2003
Author(s): Stewart GB, Shields BJ, Fields S, Comstock RD, Smith GA.
Journal: Dental Traumatology
Date: 2009
Type of Article: Retrospective
Main Purpose: Describes the association of consumer products and activities with dental injuries

OBJECTIVE:
Describe the association of consumer products and activities with dental injuries among children 0-17 years of age treated in United States emergency departments.

DESIGN:
A retrospective analysis of data from the National Electronic Injury Surveillance System, 1990-2003.

RESULTS:
- There was an average of 22 000 dental injuries annually among children <18 years of age during the study period (average annual rate of 31.6 dental injuries per 100 000 population)
- The greatest number of dental injuries occurred among children 1–2 y/o (24.5% of the dental injuries among children 17 y/o and younger)
- When evaluated by age group, children <7 years had the highest annual dental injury rate (48.3 per 100 000 population), followed by 7–12 year olds (27.7 dental injuries per 100 000 population) and 13–17 year olds (12.6 dental injuries per 100 000 population). 

- Males sustained dental injuries more often than females in every age group and in every consumer product group (63.5% of all dental injuries)

- Children with primary dentition (<7 years) sustained over half of the dental injuries recorded.
- Floors, steps, tables, and beds were the consumer products within the home most associated with dental injuries.
- Outdoor recreational products/activities were associated with the largest number of dental injuries among children with mixed dentition (7-12 years); almost half of these were associated with the bicycle, which was the consumer product associated with the largest number of dental injuries.
- Among children with permanent teeth (13- to 17-year olds), sports-related products/activities were associated with the highest number of dental injuries.
- Of all sports, baseball and basketball were associated with the largest number of dental injuries.


CONCLUSION:
This is the first study to evaluate dental injuries among children using a national sample. Knowledge of these consumer products/activities allows for more focused and effective prevention strategies.

Assessment of Article:  Level of Evidence/Comments: II

Monday, June 5, 2017

Management of Facial Bite Wounds

Department of Pediatric Dentistry
Lutheran Medical Center


Resident’s Name:  Nicholas Paquin                                                             Date: 06/06/2016
Article Title: Management of Facial Bite Wounds
Author(s):  P. Stefanopoulos, DDS, A. Tarantzopoulou, DDS
Journal:  Dental Clinics of North America
Date:  2009
Major Topic: Management of Bite Wounds
Type of Article: Review and Guidelines
Main Purpose: Present best practice for facial bite wounds
Summary of article:  15% of all dog (“hold and tear, mostly on the lips, nose or cheeks), cat (puncture)and human bites (crush wounds, tend to involve the ear, sometimes the lower lip) are located on the face and are considered complex injuries contaminated with unique polymicrobial inoculu.  These can be life-threatening and have enough force to cause structural damage to the facial skeleton. 

Bites:
·      soft tissue wounds – punctures, lacerations and avulsions, with and without actual tissue defect. 
·      Bacteria found in bite wounds can be both aerobic and anaerobic.  Virus are also something to be aware of hepatitis B and C, HIV, syphilis from human bites, rabies from animals. 
·      Facial wounds are generally have low infection rates due to the rich blood supply.  Dog bites have moderate risk for infection especially if treated with in 6-12 hours.  Cat bites are higher in infection due to the deep puncture wound, human bites usually exceed the threshold bacteria count due to bacteria in the saliva. 

Treatment: 
·      Life preserving emergency treatment first. 
·      Assess and rule out facial fractures.  Lacerations to the eye are of particular concern due to damage to underlying structures. 
·      Assess for infection.  Tetanus-prone, if it has been more then 5 years since last tetanus immunization, booster is recommended. 
·      Most superficial bites can be treated in the outpatient setting but those with system toxicity, rapidly advancing cellulitis, or infection constitute hospitalization, also those with more serious injuries.  I
·      Irrigate the bite with normal saline (19-gauage catheter on the 30-60ml syringe, which delivers about 5-8psi, 250ml- 500ml), remove necrotic tissue.  Avoid high pressure irrigation in area containing loose areolar tissue, example eye lids and children’s cheeks to avoid excessive edema.  Surgical debridement if needed but take care not to remove excessive tissue that maybe needed for reconstruction.
·      Primary wound closure is recommended within 24 hours of an uninfected facial bite lacerations.  IF beyond that delayed treatment may be necessary due to edema, wait 4-5 days.  If repaired after 24 hours there might be a higher risk for infection but lower risk for scaring.  Over infection may preclude closure and then revisions may have to be made. 
·      Antibiotics:  Administration can be prophylactic or therapeutic.  It is unclear that healthy patient with fresh clinically uninfected wound benefit from prophylactic antibiotics.  However a cat puncture wound it is recommended due to the high-risk characters.

Efficacy of revascularization to induce apexification/apexogenesis in infected, non-vital immature teeth: a pilot clinical study

Department of Pediatric Dentistry
Lutheran Medical Center
           
Resident’s Name: Brian Darling                                                                                             Date: 6/7/2017
Article Title: Efficacy of revascularization to induce apexification/apexogenesis in infected, non-vital immature teeth: a pilot clinical study
Author(s): Shah, N et al
Journal: Journal of Endodontics
Date: 2008 34 (8): 919-925
Major Topic: Revascularization of Immature Teeth
Type of Article: Case series
Main Purpose: This article aimed to describe the results of a series of cases in which revascularization is performed on traumatized, nonvital, immature teeth.

·      Root development takes place about 2 years after tooth has erupted into the oral cavity
·      Methods
o   14 traumatized, nonvital, immature teeth
o   Irrigation with 3% hydrogen peroxide and 2.5% sodium hypochlorite
o   Light cotton pellet with formocresol as interappointment dressing was placed in chamber and IRM seal
o   Tooth left open 24-48 hours if frank purulent discharge
o   Revascularization done once tooth was asymptomatic
o   Sterile 23 gauge was placed 2mm beyond working length to induce bleeding
o   Dry cotton pellet used to stop bleeding once at cervical area by dabbing 3-4mm into canal and pulp chamber and held there for 7-10 minutes to allow clot formation in apical 2/3 of canal
o   Sealed access with glass ionomer cement extending 4mm into coronal portion of root canal system
o   Follow-up at 6 month intervals
·      Results
o   Complete resolution of clinical signs and symptoms and appreciable healing of periapical lesions was evident in 11/14 cases
o   Thickening of lateral walls evident in 8/14 cases
o   Increased root lengthin in 10/14 cases
o   Zero cases presented with pain, reinfection, or enlargement of periapical radioulucency at recall appointments
·      Apexogenesis is a natural physiologic process of root development. This term is often used to describe the procedure of preserving pulp vitality in traumatized tooth with pulp involvement so that the affected tooth could develop its full growth potential
·      Maturogenesis has been suggested as a better term than apexification because the entire root is allowed to mature rather than just the apex
·      Revascularization of infected, nonvital infected, immature tooth could stimulate regeneration of apical tissues and induce apexogenesis
·      Limitations of calcium hydroxide apexification
o   Length of time required – may take 6-24 months to form apical barrier
o   Apical barrier formed is often porous and not continuos or compact, and so requires obturation after barrier formation
o   Obturation difficult to form tight seal without splitting tooth
o   No further development of root
o   Hygroscopic and proteolytic properties of calcium hydroxide may make tooth more brittle
o   Calcium hydroxide may damage cells at the apex that have regenerative capacity
o   Not uncommon for these teeth to fracture (after four years, one report said 77% of most immature teeth and 28% of most fully developed teeth)
·      MTA apexification
o   MTA apexification can be done in 1 visit
o   MTA is biocompatible with osteoinductive properties and sets in presence of moisture  
·      Rationale for revascularization is that if a sterile tissue matrix is provided in which new cells can grow, pulp vitality can be reestablished
·      Infection control is largely via chemical debridement – sodium hypochlorite or chlorhexidine, or povidone-iodine or antibiotic paste
·      There are several suggested mechanisms of how revascularization occurs
·      Advantages of revascularization
o   Shorter treatment time
o   Cost-effective (decreased number of visits and no additional material required)
§  Continued root development and strengthening of root
·      Disadvantags of revascularization
o   Calcification of entire canals may make esthetics compromised and future endodontic treatment more difficult
o   Post and core needed for restoration (because you can’t violate the apical 2/3 of the canal with revascularization)

Remarks:
1- I wonder what they did to treat the 3 cases where signs/symptoms did not resolve
2- Did they use anesthetic with vasoconstrictor?
3- Only placed GIC over blood clot?
Assessment of Article:  Level of Evidence/Comments: III