Tuesday, July 25, 2017

Association of Mutans Streptococci Between Caregivers and Their Children

Resident’s Name: Carol Caudill                                                                        Date: 7-26-2017
Article Title: Association of Mutans Streptococci Between Caregivers and Their Children
Author(s): Douglass, Li, Tinanoff
Journal: Pediatric Dentistry
Date: Sept/Oct 2008
Major Topic: Relationship between levels of mutans streptococci in caregivers and children and interventions
Type of Article: literature review
Main Purpose: To review sources of MS colonization in children and to study what effect MS levels in primary caregivers have on children’s MS colonization. Evaluate studies examining interventions to reduce MS transmission
Key Points: (2 lines Max): There is strong evidence that mothers are the primary source of mutans streptococci transmission to children. More studies need to be done for fathers and other caregivers. More studies also need to be done to examine the effectiveness of microbiological interventions.

·      Incidence of dental caries has decreased in most industrialized countries in the past 30 years; however, it remains highly prominent in children with low SES and in underdeveloped countries
·      Mutans streptococci most frequently associated with caries are strep mutans and strep sobrinus
·      Children with high MS levels have higher levels of caries
·      MS colonization of the oral cavity in children is believed to be caused by transmission from the primary caregiver
·      Performed a literature search in PubMed and selected 46 studies published between 1975 and 2006
·      Data have consistently shown that children acquired at least 1 phenotype or genotype of MS isolate identical to their mothers
·      Studies are mixed about whether fathers are an MS source
·      This is further complicated by the fact that on the whole studies found that spouses share at least 1 identical MS isolate
·      Children were most likely to harbor MS when their mothers were highly colonized
·      Different intervention studies tried different methods to decrease mom’s MS levels to try to decrease cavities in children. Agents included 1% chlorhexidine gel with dietary counseling, prophylaxis, OHI, and restorative treatment; 10% chlorhexidine varnish; 40% chlorhexidine gel; iodine, NaF; xylitol gum. These studies had mixed results
·      Problem with early investigations: mostly used an older method to distinguish MS isolates that may have lacked sensitivity and accuracy
·      Genotyping suggests that mothers are the primary MS transmission source
·      We can’t rule out that fathers may also be a source of MS for their children. However, more studies are needed
·      Studies may be complicated by the fact that MS can be transmitted between mothers and fathers
·      Low SES is a strong risk factor for MS colonization but few studies have examined its role in the transfer of MS
·      Limitations in the maternal intervention trials make comparisons and generalizability difficult and there is no data regarding the cost effectiveness of these programs.

Assessment of Article:  Level of Evidence/Comments: Level 1, literature review

Standard and Transmission-Based Precautions: an update for dentistry

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name:        Wayne Dobbins                                                                          Date: 7/26/17
Article Title: Standard and Transmission-Based Precautions: an update for dentistry
Author(s): Harte JA
Journal: J Am Dent Assoc 2010;141;572-581
Date: May 2010
Major Topic: Prevention of disease transmission in the dental clinic and setting, etc.
Type of Article: Literature review and expert opinion
Main Purpose: Provide dentists information on the current standards of practice concerning infection control
Key Points: Dental health care professionals and their staff must be familiar with, and must adhere to, the CDCA’s most recent Standard Precaution guidelines, as well as the additional Transmission-Based Precautions, during treatment of patients.
Standard Precautions apply to any contact with bodily fluids, secretions, and excretions (except sweat). All potentially infectious materials are to be treated as though they are infectious; thus the degree of precaution is dictated by the procedure, not by the medical history of the patient. Standard Precautions include the following points:
·         Hand hygiene (antisepsis hand rub & soap and water)
·         Use of personal protective equipment
·         Proper handling and sterilization of contaminated materials and equipment
·         Use of engineering and work practice controls
·         Respiratory hygiene
·         Safe injection practices

Transmission Based Precautions are a second set of guidelines that are used when dealing with patients known or suspected to be infected with select highly transmissible diseases, and are used in conjunction with Standard Precautions.
·         Contact
o   PPE
·       Patient placement
Patient transport
·         Droplet
o   PPE
o   Patient placement
o   Patient transport

·         Airborne
o   PPE
o   Patient placement
·       Patient transport
1-      New CDC guidelines published in 2015 (not really relevant to dentistry).
Assessment of Article:  Level of Evidence/Comments: VII

Monday, July 24, 2017

Survival Rate of Atraumatic Restorative Treatment (ART) Restorations Using a Glass Ionomer Bilayer Technique with a Nanofilled Coating: A Bi-center Randomized Clinical Trial

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:       Suhyun   Rue                                                  Date: 7/26/17
Article Title: Survival Rate of Atraumatic Restorative Treatment (ART) Restorations Using a Glass Ionomer Bilayer Technique with a Nanofilled Coating: A Bi-center Randomized Clinical Trial
Author(s): ): Daniela Hesse, DDS, MSc, PhD • Clarissa Calil Bonifácio, DDS, MSc, PhD • Marcelo Bönecker, DDS, MSc, PhD • Camila de Almeida Brandão Guglielmi, DDS, MSc, PhD • Carolina da Franca, DDS, MSc, PhD • Willem Evert van Amerongen, DDS, PhD • Viviane Colares, DDS, MSc, PhD • Daniela Prócida Raggio, DDS, MSc, PhD
Journal: Pediatric Dentistry
Date: : Jan / Feb 2016
Major Topic: Survival Rate of Atraumatic Restorative Treatment
Type of Article: Randomized -Controlled  Clinical Trial
Main Purpose:
1)  Investigate  the survival rate of  interproximal  atraumatic restorative treatment (ART) restorations  in primary molars using two different insertion techniques( conventional vs. bilayer technique)  and two different surface protection materials (  Petroleum jelly(PJ) vs. Nanofilled coating(NC)) after 2 years of follow-up
2) Compare the results of the 2 cities where treatments were performed
Key Points/Summary:
-Atraumatic restorative treatment (ART) is defined as part of a minimal intervention philosophy to manage dental caries. It aims to restore teeth that already present cavitated carious lesions to prevent the development of lesions by sealing susceptible pits and fissures.
-The material of choice is high-viscosity glass ionomer cement (GIC). It is believed the material consistency may contribute to incorrect cervical adaptation in interproximal cavities. This factor may put the survival rate of restorations at risk. Aiming to achieve better clinical results, a randomized-controlled clinical trial was conducted

     -Total of 389 six- to seven-year-olds were selected from 2 cities in Brazil and randomly assigned into 4 groups & one cavity per child was included in study
-The treatments were performed in accordance with the ART approach, and no local anesthesia or radiograph exam was used. The outer dentin was removed with hand instruments.

-Group 1(Control=Conventional+PJ ): conventional ART restoration ( high-viscosity GIC was hand-mixed  using a powder/liquid ratio of 1:1), after inserting the GIC, the press-finger technique was applied. To protect the restoration, a thin layer of petroleum jelly (PJ) was applied.)
-Group 2 (experimental=Bilayer +PJ): bilayer technique ART restoration ( a first layer of GIC with “flowable” consistency ( using a powder/liquid ratio of 1:2) applied at the bottom of the cavity, the second layer was mixed using a powder/liquid ratio of 1:1) and inserted in the cavity before the final setting of the first layer. To protect the restoration, a thin layer of PJ was applied.
-Group3 (experimental=Conventional+NC): conventional ART restoration ( To protect the restoration, the nanofilled coating (NC) was applied with a micro-brush on the occlusal and interproximal surfaces.)
-Group 4 (experimental=Bilayer+NC): bilayer technique ART restoration (The surface protecting was performed by applying the NC like Group 3)
-All groups were evaluated after 1,6,12,18,24 months

-The bilayer technique of glass ionomer cement insertion can improve the survival rate of interproximal ART restorations in primary molars
-The application of a nanofilled coating does not influence the survival rate of interproximal ART restorations in primary molars.
-The city in which treatments are performed can have an influence in the survival rate of ART restorations.

-The explanation for a higher survival rate of bilayer techniques could be the “flowable” GIC provides lower stress concentration on the occlusal surface of the material(the flowable layer could dissipate the masticatory load stress, which could protect  restoration against breakdown or detachment caused by material fatigue over time)
-Surface protection of GIC is recommended to ensure the mechanical properties of the material. But this study verifies that the coated GIC had no influence on the survival rate of interproximal restorations in primary teeth
-There were significant differences in the survival of restorations when comparing cities where the restorations were performed. The restorations placed in Barueri were nearly 2.5 times more likely to survive than the ones placed in Recife. This finding is related to the differences in socioeconomic indexes and caries prevalences of the populations of both cities.

-What is the difference between Interim Therapeutic Restorations (ITR) and Atraumatic restorative treatment (ART)?

Assessment of Article:  Level of Evidence/Comments: Since this article is a randomized controlled trial, it has an internal validity of I

Sunday, July 23, 2017

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name:   Olga Raptis                                                                                         Date: 07/23/17
Article Title: Eating Disorders and oral health: a matched case- control study
Author(s): Johansson et al.
Journal: European Journal of Oral Sciences
Date: 2012
Major Topic: Eating disorders and oral health
Type of Article: Case-control study 
Main Purpose: The comparison in “oral health status of patient with eating disorders (EDs) with sex- and age- matched controls, with a view to identify self-reported and clinical parameters that might alert the dental professional to the possibility of EDs”
Key Points: (2 lines Max): Main conclusion or the most interesting

·       3 types of eating disorders:
o   Anorexia nervosa (AN): underweight and food restriction
o   Bulimia nervosa (BN): binge eating and inappropriate compensatory behaviors; self-induced vomiting (VOM), laxatives use, and excessive exercise.
o   Eating disorder not otherwise specified (EDNOS): mix of AN- and BN- like atypical EDs
·       Previous studies on Oral health in ED have showed that correlation of EDs and dental caries are contradictory but are more consistent regarding dental erosion and bulimic behavior.
·       Some symptoms are permanent (i.e. dental erosion and caries) others reflect the expression and intensity of the disease (i.e. gingivitis, mucosal lesions, enlargement of salivary glands and xerostomia)

·       Dental and other healthcare providers often prefer to not pursue suspicions of EDs due to fear of losing the patient or insufficient confidence in their suspicion. Patients with EDs often avoid healthcare professionals and conceal the true origin of their problem due to guilt, shame, and self-denial of the disease.
·       Study summary:
o   54 patients: 50 females and 4 males in clinical for EDs treatment and the control group of 54 subjects matched for sex and age was selected from the ordinary recall patients at a Public Dental Health Clinic.
o   Given a 91-item questionnaire which was used to exclude patients with a risk of having EDs from the control. Same investigator recorded:
§  EOE (dry/cracked lips and enlargement of parotid gland)
§  IOE (Visible plaque index, gingival bleeding, dental caries and grading of dental erosion and assessment of intraoral tissue; gingival trauma, ulcers, blisters, and/or esophagitis)
·       Study Results:
o   Mean age of onset :16 y/o and the mean duration of the disease was 4.4 years
o   Signs of dry and/or cracked lips or parotid gland swelling, were significantly more common in ED patients than in controls. Esophagitis and the severity of dental erosion was also more common in patients with EDs. Similar DMFT, DMFS, IP caries, and Lower Gingival Bleeding Index ( due to obsessive hygiene) 
Dental team should look out for symptoms and signs such as present dental problems indicative of EDs: 
Burning mouth, dry/cracked lips, good oral hygiene, parotid gland swelling, and dental erosion

1- According to the study: “only a few dentists inform patients/parents about their suspicion of EDs, and/or report insufficient knowledge of EDs and their clinical diagnosis.
2- Therefore, an increased knowledge of EDs and their effect on oral health is likely to increase the probability of intervention by the dentist” and lead to early detection and intervention for ED patients.

Assessment of Article:  Level of Evidence/Comments:   II-3 Case-Control Study

Wednesday, July 19, 2017

Pregnancy, breastfeeding, and drugs used in dentistry

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Brian Darling                                                                     Date:  7/19/2017
Article Title: Pregnancy, breastfeeding, and drugs used in dentistry
Author(s): Donaldson M, Goodchild JH
Journal: JADA
Date: 2012: 143: 858-71
Major Topic: Drug safety in pregnant and breastfeeding women
Type of Article: Review of topic – medications and pregnancy/breastfeeding
Main Purpose: This article aimed to describe the level of safety of drugs commonly used in dentistry for women who are pregnant or breastfeeding.
Key Points: Dentists should weight the risk to the fetus versus the benefit to the mother when choosing medications for pregnant and breastfeeding women.
·      2/3 women take prescription medications during pregnancy
·      Be mindful that women of child-bearing age may be unknowingly pregnant and that they may conceive while still receiving the medication 
·      Placental transport of substances between fetus and mother usually occurs at the 5th week of embryonic life
·      Greatest teratogenic risk to the fetus is from 3-8 weeks after conception (5-10 weeks gestation, with week 1 beginning on the 1st day of the last menstrual period)
·      Almost every drug can pass from the mother to the fetus (concept of “placental barrier” is a misnomer)
·      Generally safe to use category A and B drugs
·      Avoid prescribing drugs in the 1st trimester
·      AAP supports breastfeeding alone for the 1st 6 months
·      Infants are exposed to much higher concentrations of drugs during pregnancy than during lactation, so most drugs used during pregnancy are also safe during breastfeeding
o    Exceptions: Benziodiazepines and aspirin and some other medications
·      Chlorhexidine use decreases caries risk and bacterial transmission from mother to children
·      Prenatal fluoride supplementation is not supported by the AAPD
·      Fluoride is category C drug
·      NSAIDs (particularly ibuprofen) may cause embryonic implantation disturbances, inhibition of parturition, contraction of ductus arteriosus leading to maternal pulmonary hypertension
·      NSAIDs are also linked to gastrochisis (fetal organs develop outside the abdominal wall). Aspirin, pseudoephedrine, and phenylpropanolamine are linked to gastrochisis
·      Antibiotics may alter bowel flora and cause diarrhea in babies of breastfeeding mothers.
·      Prednisone and dexamethasone are associated with oral clefts when given during the 1st trimester
·      Acetaminophen is the safest analgesic for pregnant patietns
·      Ibuprofen is category C/D and should NOT be used during pregnancy but is safe for breast-feeding
·      Tetracyclines are not to be used during pregnancy because they can be deposited in embryo’s bones and teeth where there’s active calcification BUT they may be used during breast-feeding
·      Amoxicillin, azithromycin, cephalexin, clindamycin, erythromycin, penicillin, and metronidazole are category B and safe for pregnancy and breast-feeding EXCEPT metronidazole, which should not be used for breast-feeding patients but can be used during pregnancy
·      Nystatin is the safest antifungal agent for pregnant patients
·      Lidocaine and prilocaine are category B but prilocaine is associated with increased risk of methemoglobinemia
·      Articaine, mepivacaine, and bupivacaine are category C but mepivacaine and bupivacaine can be used in breast-feeding patients
·      Increased risk of methemoglobinemia with use of prilocaine, tetracaine, and benzocaine
·      Category C topical anesthetics are benzocaine, dyclonine, and tetracaine
·      Benzodiazepines are category D and X medications because they may cause fetal abortion, malformation, intrauterine growth retardation, functional deficits, carcinogenesis, mutagenesis
·      Zaleplon and zolpidem are preferable to benzodiazepines for sedation in pregnant women but are category C
·      Emergency medications should generally be used because of the benefit to the mother outweighs risk to fetus – especially for epinephrine, albuterol, antihistamines, flumazenil, nitroglycerin
o   Flumazenil is category C
o   Epinephrine is category C
o   Diphenhydramine is category B
o   Albuterol is category C – some research has shown increased risk of congenital malformations associated with albuterol use during pregnancy but there are also studies showing increased risk of adverse pregnancy outcomes in women with untreated asthma 

Results of controlled studies in women fial to demonstrate a risk to the fetus in the 1st trimester (and there’s no evidence of risk in later trimesters), and the possibility of fetal harm appears remote
Either the results of animal reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women
Results of animal reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in 1st trimester and there is no evidence of risk in later trimesters
Either the results of studies in animals have revealed no adverse effects (teratogenic, embryocidal, or other) on the fetus and there are no controlled studies in women
Results of studies in women and animals are not available; drug should be given only if potential benefit justifies the potential risk to the fetus
There is positive evidence of human fetal risk, but the benefits of use in pregnant women may be acceptable despite the risk (example, the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective)
Results of studies in animals or humans have demonstrated fetal abnormalities or evidence of fetal risk based on human experience, or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit; use of drug is contraindicated in women who are or may become pregnant

https://www.betterhealth.vic.gov.au/health/healthyliving/baby-due-date à The unborn baby spends around 37 weeks in the uterus (womb), but the average length of pregnancy, or gestation, is calculated as 40 weeks. This is because pregnancy is counted from the first day of the woman’s last period, not the date of conception which generally occurs two weeks later, followed by five to seven days before it settles in the uterus. Since some women are unsure of the date of their last menstruation (perhaps due to period irregularities), a pregnancy is considered full term if birth falls between 37 to 42 weeks of the estimated due date. 

A baby born prior to week 37 is considered premature, while a baby that still hasn’t been born by week 42 is said to be overdue. In many cases, labour will be induced in the case of an overdue baby.

Assessment of Article:  Level of Evidence/Comments: III