Tuesday, June 5, 2018

Local Anesthesia and Oral Surgery in Children

Local Anesthesia and Oral Surgery in Children

Resident’s Name: Wayne Dobbins DDS, MS                                                                 Date: 06/6/2018

Article Title: Local Anesthesia and Oral Surgery in Children
Author(s): Stephen Wilson
Journal: Pediatric Dentistry, Infancy Through Adolescence, 5th Ed
Date: 2012
Major Topic: Steps in preforming local anesthesia in pediatric patients
Type of Article: Background information and expert opinion
Main Purpose: Local anesthesia in Children
Key Points/Summary:
-Topical anesthesia à Decrease the pain from injection. Questionable effects but most agree that it helps. Operator technique is more important in limiting the pain felt: Verbal distraction, vibratory stimulation, cotton swab pressure, slow injection: 1 carpule should take 1 minute to deposit

- Maxillary primary and permanent molar: Injection should penetrate the mucobuccal fold and be inserted to a depth that approximates the apices of the roots.
- Max primary canines and permanent incisor and canine: Local infiltration or an infraorbital block
- Palatal tissue anesthesia: these are very painful and should only be used if necessary to get full palatal anesthesia. Pressure can be applied to lessen the pain.
- Mandibular anesthesia: IAN blocks can be used.  If missed go slightly higher. Long buccal can be used to anesthetize the buccal gingival.
- PDL injection might cause hypoplasia and decalcification of succedaneous teeth.

Oral surgery in Children:
Considerations: Good medical HX, appropriate medical and dental consultations, anticipate emergency situations, have pedo forceps and name them kid friendly names, child and parent should be well prepared for the procedure and what to expect, throat guard or rubber dam should be placed to prevent aspiration, support the jaw on mandibular extractions.
- Maxillary molar: Root fracture is possible. Should be luxated palatally first then buccally.
- Maxillary anterior:  Rotational movement used to twist out.
- Mandibular molar:  Must support mandible, buccal palatal movement
- Mandibular anteriors:  Careful not to displace adjacent teeth due to conical roots. Rotational force.
Root fracture: If the root can be accessed and is visible then an effort should be made to extract it. If not accessible, or several attempts have failed à leave the root fragment due to damage to the succedaneous tooth.

Soft tissue procedures:
-Biopsies: If the lesion is less than .5cm an excisional biopsy is best.  Consideration must be taken if the lesion appears vascular and can be checked with aspiration.  Some areas such as the tongue may require sedation for biopsy due to the sensitivity of the tissue. Resorbable sutures are preferred.
Maxillary labial: When frenum is a causative factor in maintaining a diastema. (Wait until after the permanent canines have erupted)

Consumer products and activities associated with dental injuries to children treated in United States emergency departments, 1990-2003

      Resident’s Name: Suhyun Rue, DMD                                                      Date: 06/06/2018
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.
- 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.
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

Sunday, June 3, 2018

Management of Facial Bite Wounds

Article Title: Management of Facial Bite Wounds
Author(s): Stefanopoulos PK, Tarantzopoulou AD
Journal: Dent Clin N Am
Date: 2009; 53: 691-705
Major Topic: Facial bite wounds
Type of Article: Topic overview
Main Purpose: This article aimed to discuss the management of bite wounds to the face.
Key Points: It is important to consider the cause of the bite when managing bite wounds and treat as soon as possible.
·      ~15% of dog, cat, and human bites are on the face
·      Dog bites to the face are the most common
·      3 types of soft tissue trauma from bites: punctures, laceration, avulsions
·      Dogs create a “hole-and-tear” effect à torn tissues and adjacent punctures
·      Dog bites are usually on the lips, nose, or cheeks whereas human bites tend to involve the ear and lower lip
·      Rabies is the most dreaded of bite wound infections
o   Rabies should be especially considered when bitten by bat, raccoon or fox
·      Facial bite wounds have low infection rates due to rich blood supply to area
·      Higher infection rates from puncture wounds, especially if from cats
·      Bite wounds are tetanus prone patient should be immunized if they have had less than 3 doses of tetanus toxoid or more than 5 years since the last dose
·      Irrigation and removal of necrotic tissue is important
·      Debatable about after what period of time the clinician should wait to close wound. Generally this is 24 hours but may also delay suturing if there is over infection, gross edema, foreign bodies, or visible contamination
·      Higher infection risk from human and cat bites than from dogs
·      Amoxicillin/clavulonate is antibiotic of choice for prophylaxis of bite wounds
Primary Regimen
Alternative regimen/allergy
Clindamycin + ciprofloxacin
Cefuroxime axetil
Clindamycin + trimethoprim-sulfamethoxazole
Assessment of Article:  Level of Evidence/Comments:

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

Article Title: Efficacy of revascularization of 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 length in 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 continuous 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   Physical barrier of calcium hydroxide prevents migration of multipotent undifferentiated mesenchymal cells into the canal and regeneration of lateral dentinal walls
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
·      Disadvantages 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)

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