Wednesday, June 20, 2012

Prolonged Bleeding Following Tongue Piercing: a Case Report and Review of Complications

Resident: FreitasArticle Title: Authors: Rosivack, et al.
Journal: Pediatric Dentistry 25:2 2003

Main Purpose:
-Case report of prolonged bleeding after tongue piercing and review of potential complications after an intraoral piercing.

-Reported complications: fractured teeth, gingival recession of the lingual of mandibular anteriors, gingival injuries, infections of the tongue. Increased saliva producation and impaired speech have also been reported.

Case Report:
-15 year old male brought to ER in NJ by his mother due to a chief complaint that his tongue would not stop bleeding under his tongue.
-Patient had his tongue pierced 6 month prior, however after 1 month he removed the barbell and the piercing healed uneventfully.
-4 days before his ER visit, he had his tongue pierced a second time. He removed the barbell 3 days later and noticed continued bleeding and a blood clot on the ventral surface.
-Clinical exam in the ED revealed a 2cm hematoma on the ventral surface; with bleeding and surrounding necrotic tissue.
-Bilateral mandibular blocks and local infiltration with 3.6ml of lidocaine.
-Necrotic tissue was removed with surgical scissors, 3 sutures placed with 4.0 chromic gut, bleeding stopped immediately with suture placement.
-Tetanus Toxoid (0.5ml) and 10 day course of penicillin given.
-1 Week eval revealed good healing.

-Bleeding is typically not a complication of tongue piercings, because the lingual arteries and veins ar found running laterally.
-One should first try to establish hemostasis with guaze and pressure. If bleeding is still present then topical agents can be used such as aluminum chloride, silver nitrate, ferric sulfate, and topical thrombin; as well as LA with epi. Another option would be electrocautery or a laser.
-It's important to discuss potential complications and review a patient's medical history when they are considering an intraoral piercing or currently have one.

The oral health of homeless adolescents and young adults and determinants of oral health: preliminary findings

Kyung-Hong Cal Kim

The oral health of homeless adolescents and young adults and determinants of oral health: preliminary findings

Authors: Chi D, Milgrom P

Special Care Dentistry 2008

To identify factors associated with self-reported oral health in homeless adolescents and young adults aged 14 to 28.

Background Information:
-In 1998 study estimated that 8% of surveyed youths of ages 12 to 17 years experienced homelessness at least once during a 12-month period.
-12% of the homeless population in the US consisted of young adults under the age of 25 years in a publication from 2001.

-An 11-page, 86-item survey was distributed to the first 55 homeless adolescents and young adults (HAYA) aged between 14 to 28 years presenting to the 45th St evening clinic in Seattle area for care on three evenings from 6:00 to 9:30 PM in Feb/Mar 2006.
-$5.00 gift certificate to a supermarket upon completing the survery.
-49 surveys were returned, 45 valid survey remained after illegible or incomplete surveys were removed.

-68% of HAYA reported having no medical insurance, and 85% reported having no dental insurance.
-47.1% had no dental home.
-Reasons for not brushing regularly: 45% said they do not have time, 35% do not always have toothpaste, 33.3% don’t always have a toothbrush, 17.9% said it was hard to find a place to brush, and 10.3% said it was hard to find clean water
-1/3 of those surveyed rated their oral health as either very bad or bad, 36% “okay,” and the other 1/3 as either good or very good.
-Non-high school grads, mixed race youths, and meth users had significantly higher self-reported oral health.
-Self reported dental problems include: sensitive teeth (52.6%), discolored teeth (48.6%), toothache (52.6%), sore or bleeding gums (27%), and dental abscess (2.9%)
-Similar proportions of youths with dental insurance reported having a toothache, a broken tooth, discolored teeth, or sore gums than those without dental insurance.

Preliminary study with a very small sample size may not accurately describe current perception regarding their oral health in homeless adolescents and young adults, but it does suggest future studies that may be beneficial in understanding the dental needs of HAYA and formulating an effective approach to improve their oral health. What would have been very nice is to include in the study is dental screening of the patients who reported that they are “in good health.” As mentioned in the article, lack of knowledge in oral health may make them believe they are in good health and the only problems they can see are yellow teeth or small chip on the incisors, while severely perio-involved posterior teeth are being held on by cake of calculus. While working in a homeless clinic in the basement of a homeless shelter, there was nothing more heartbreaking than seeing a “newly-homeless” high school dropout who comes in for an extraction. Still having 31 other teeth to chew with, they were the hardest ones to discuss improving oral health, since they couldn’t see the need to do so as long as the pain they come in for is taken care of. When they struggle to get through each day, I guess it isn’t fair for us to expect them to see a whole picture or set a long term goal to improve their health. It would be interesting to see some followup studies from this article that may suggest effective ways to reach out to them.

Overweight and Dental Caries Among US Children

Resident: Swan
Article Title: Exploring the Association Between Overweight and Dental Caries Among US Children
Authors: Macek, et al.
Journal: Pediatric Dentistry 28:4 2006
Main Purpose: Examine relationship between age-specific BMI and dental caries among US kids
Background: 16% of US children and teenagers are overweight and the % is increasing. Minority and low socioeconomic status-youth are at greater risk. Overweight kids often consume foods high in fats and refined carbs. The authors hypothesized that overweight might be a marker for dental caries in kids due to relationship between refined carbs and caries. 
Methods: Data from the NHANES survey (1999-2002) were used.  Outcome variables included 1)measures of dental caries prevalence and 2) caries severity in both dentitions, both of which were represented by dft and DMFT. Multiple logistic regression used to determine if BMI for age could be a predictor of caries prevalence.
Results: Controlling for confounders,
1.  there was no statistically significant association between BMI for age and careis prevalence in either dentition.
2. Also, no sig. association with caries severity in the primary dentition. 
3.  Overweight kids with past caries experience in permanent dentition actually had lower DMFT than their normal-weight peers.
Discussion:  Let's just keep this piece of information from our overweight patients...This study sheds interesting light on the relationship between carbohydrate consumption and caries prevalence and severity.  Definitely still a good idea to counsel patients about healthy diet choices, for many different reasons...

Tuesday, June 19, 2012

The Dental Neglect Scale in adolescents

Resident’s Name:                  Jessica Wilson     

Article title: The Dental Neglect Scale in adolescents

Author(s): Coolidge et al.
Journal: BioMed Central
Year. Volume (number). Page #’s:  2009. 9:2.
The Dental Neglect Scale (DNS) is a tool to assess the extent to which an individual cares for his/her teeth. It has been found to be a valid measure of dental neglect in children and adults. It is suspected that it can also be a helpful tool to evaluate adolescents. Adolescence is a time when personal oral health behaviors may internalize and become habits as parents tend to become less involved in their oral care.
117 adolescents from seven different youth clubs in the Seattle area completed the DNS at two different times. They, as well as their parents, were asked if the adolescent currently sees a dentist and the teens received a light/mirror dental screening by calibrated personnel.
Significantly higher DNS scores (higher levels of dental neglect) were observed in adolescents with visible caries, who had not had a check-up in the past three years and who do not go to a dentist.
DNS scores were also significantly related to age, with older teenagers having higher levels of dental neglect.
Of the adolescents who had a dentist to go to, 21% had not had a check-up in the last three years.
The DNS appears to provide similar insight in this sample of adolescents as it has previously with children and adults.

Oral Health Knowledge and Behaviors Among Adolescents with Type I Diabetes

Resident: Elliot Chiu
Title: Oral Health Knowledge and Behaviors Among Adolescents with Type I Diabetes
Journal: International Journal of Dentistry – 2010
Main Purpose: To survey oral health knowledge, attitudes, and behaviors among adolescents with diabetes.
-Survey of 90 subjects with type I diabetes age 12-19
-Questions included self-reported oral health and dental conditions, history of dental treatment, home care behaviors, and opinions of the importance of dental care
Key Points
-92% reported receiving instructions on proper toothbrushing and flossing
-44% knew that perio disease is associated with diabetes
-32% knew that perio disease can start in childhood with bleeding gums
-42% did not floss
-Brushing frequency was highly varied, but median frequency was 1x / day
This survey shows that these diabetic patients are being instructed on “how” to brush and floss, but are not keeping up with the recommendations at home. The survey also shows that over half of patients do not understand the significance of perio disease in relation to diabetes.
Perhaps spending more time on perio disease and “why” OH is important will help motivate our patients.

The relationship between methamphetamine use and increased dental disease

Resident Name: Sadler
Article Info: The relationship between methamphetamine use and increased dental disease
Vivek Shetty DDS et al.
Journal of the American Dental Assoc. 2010 March
Main Purpose: Compare dental problems experienced by meth users to those of the general population and demonstrate a link between meth use and dental problems.

Methods: 301 meth users aged 18 years or older were selected from a group of people undergoing treatment for meth use.  Participants filled out a self-assessment about drug use and dental issues and were visually examined for dental problems.  These drug users were compared to the general population. 
Key Points:
·         While “meth mouth” is a commonly used term, a link between meth use and dental problems has not been thoroughly examined and evidence is largely anecdotal.
·         Average age of meth users were 36.5 years with smoking meth being the preferred route of administration (64.2%)
·         Most frequent physical comorbidities was elevated BMI (65.7%), dental findings (41.3%), hypertension (21.6%), and mental abnormalities (16.3%).
·         Users reported problems with dental appearance, broken or loose teeth, and bruxism.
·         60% of users had one or more missing tooth with average number of missing teeth was 4.58.  13.3% were already wearing either partial or complete dentures
·         IV drug users had significantly higher levels of dental illness than intranasal or inhalation users.  73.3% were missing teeth compared to 57.2 % for smokers. Average missing teeth for IV was 6.2 and 3.8 for smokers
·         Dental disease is a key distinguishing comorbitiy of meth use and the rate is dental disease in meth is far higher than in the general population.
Assessment of Article:  This was a very well done study that substantiates the anecdotal evidence that meth use affects dental health.  I found the article very interesting and well written. It gave a number of great suggestions for dentists to become involved in the treatment process as restoration of appearance and self-image can be a motivator to treatment.

Overview of Complications Secondary to Tongue and Lip Piercings

Resident: Cho

Author: Maheu-Robert et al.

Journal: JCDA 73:4, 2007.

Type of Journal: Overview

Key Points:
-         Intraoral piercings involve the tongue. Perioral piercings involve the lips, cheeks, uvula, and frenum.
-         The tongue is the most common site for non-traditional body piercings, followed by the lips.
-         Risks and complications: airway compromise (secondary to swelling of the tongue), allergic reaction to metal, bleeding and risk of hemorrhage (for medically compromised patients), galvanism, gingival recession (on lingual of mandibular incisors for tongue piercing and on facial of mandibular incisors for lip piercing), hyperplastic and scar formation, increased salivary flow, inhalation of jewelry, interference with radiographic images, interference with speech, chewing, and swallowing, localized and systemic infections, nerve damage and paresthesia, pain, swelling, and tooth fracture or chipping.
-         20% infection rate with intraoral piercing.
-         Patients at risk for endocarditis should receive preventive antibiotics before the piercing procedure.

Wednesday, June 13, 2012

Survey of Oral Health Knowledge and Behavior of Pregnant Minority Adolescents

Kyung-Hong Cal Kim

Survey of Oral Health Knowledge and Behavior of Pregnant Minority Adolescents

Authors: Fadavi S, Sevandal MC, Koerber A, Punwani I.

Pediatric Dentistry Sep/Oct 2009

To compare dental visits and oral health knowledge of African American (AA) and Hispanic American (HA) pregnant adolescents in a community health clinic

Background Information:
-34% of teens will still experience a pregnancy by 20 years old
-Minority women are disproportionately affected by adolescent pregnancy

-Questionnaire that contained 21 questions to AA and HA adolescents between 12 and 20 y/o who were pregnant and were patients of a community health center clinic in Chicago, IL
-2 inclusion criteria questions + 9 demographic questions + 7 dental behavior questions + 2 knowledge questions = 20 questions (?!)
-Response rate = 100%, 111 (50 AA and 61 HA) used for studies

-Pregnant HA adolescents brushed more than AAs, while AA flossed more than HAs
-Both AAs and HAs who see a dentist every 6 months are more likely (13.6X) to see a dentist while pregnant than those who don’t see a dentist every 6 months
-Pregnant adolescents living with a boyfriend or husband are more likely (4.4X) to visit the dentist than those who do not
-About 1/3 of pregnant AA and HA adolescents reported that they were afraid of harming themselves or their babies when asked for a reason not to visit the dentists during pregnancy
-1/2 of pregnant AA and HA adolescents “correctly” believed that “tooth and gum problems could affect my pregnancy or the growth of the baby I am carrying.”
-While 1/3 of pregnant AA adolescents correctly believed that “pregnancy makes your gums bleed, swell, or become red,” more than half of HAs correctly believed this statement

Oral Health and Preterm Delivery Education

Resident: Swan
Title: Oral Health and Preterm Delivery Education: A New Role for the Pediatric Dentist
Authors: Joseph Katz, et al.
Article Type: Literature Review
Main Purpose:  Review current evidence in the literature regarding PTD/LBW and its relationship to periodontal health, and identify the pediatric dentist's role in delivering health education to expecting mothers.

Background:  Although pregnancy motivates women to be as healthy as possible, the reality is that many women neglect dental care during prenancy. Some of the reasons may include: frequent bouts with nausea, physical restraints from a growing abdomen, sensitivity and inflammation related to pregnancy gingivitis, and fear that dental treatments are potentially harmful the developing child.

Literature Review:
Human Studies:
1.  Dasanayake-400 AA first time mothers. Significant inverse relationship found between mother's level of P.Gingivalis specific serum IgG levels and birthweight. 
2.  Offenbacher-women with extensive perio disease 7 to 8 times more likely to have PLBW babies. 18% of PLBW births may be attributed to perio disease.
3.  study with Hispanic women w/ low levels of perio disease-PTD associated w/ attachment loss
4. study in London failed to observe independent association between LBW and perio disease
5. study showing that since PGE2 and TNF-A (both produced in perio disease) rise in amniotic fluid throughout pregnancy until a threshold is reached, which induces labor, perio disease may be implicated in PTD if these bioactive molecules cross the placenta.
6. study showed that perio disease may have a significant role in the pathogenesis of preeclampsia
7. Systematic review of lit: of 25 relevant studies, 18 suggested an association.

Interventional Studies:
1.  study showing that periodontal therapy significantly decreased levels of PGE2 and may help prevent threat of pregnancy gingivitis.
2.  Chilean study showed lower LBW rates in women treated for moderate periodontitis before week 28 weeks of pregnancy compared to those treated after delivery

Animal Models:
1.  study with pregnant mice directly correlated F. nucleatum infection with increased rates of premature delivery and still births, as F. Nucleatum was transmitted to the placenta.
2. Rabbit model showed chronic maternal exposure to P Gingivalis results in systemic dissemination, transplacental passage, and fetal exposure.

Conclusion:  The exact mechanism linking PTD/LBW deliveries to periodontal disease is unclear, but the association is strong based on existing research. As pediatric dentists we should consider it our responsibility to inform expecting mothers of the potential links between oral health and systemic conditions.

Oral Lesions in HIV Infection in Developing Countries: an Overview

Resident: Matthew Freitas
Journal: Advances in Dental Research 19:63, 2006.
Author: Ranganathan K

-Oral lesions that are associated with HIV are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression.
-Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries.
-By the end of 2003, over 46 million with HIV
-More than 95% of the HIV-infected live in developing countries.

-To assess the prevalence of oral lesions in different developing regions, and to better understanding these lesions in HIV disease.

-They analyzed reports of oral lesions from developing countries over a period of 14 years (1990-2004), for both adult and pediatric cases. Four subgroups were then created based on region: India, Thailand, Africa, and Latin America.

-The route of transmission in all adults was predominantly by sexual contact among heterosexuals; for pediatrics the majority was through vertical transmission.
-Predominently males affected >50% (better access to medical care)
-Adults with one or more oral lesion: ranged from 21% to 90%.
-Pediatrics with one or more oral lesion: ranged from 25% from India to a high of 63% from South Africa.
-Oral candidiasis was the most commonly reported oral lesion. (12-94%) The most common type of candidiasis in adults was the pseudomembranous type.
-Oral hairy leukoplakia (OHL) was reported from all regions. (2-40%)
-Gingivitis and periodontitis associated with HIV infection—linear gingival erythema, necrotizing ulcerative periodontitis— ranging from 2-6% and 1-28%, respectively.
-Oral ulcers were a small percentage of reported oral lesions and include recurrent aphthous ulcers, viral and tuberculous ulcers, non-specific ulcers, and those that are neoplastic.
-Oral Kaposi's sarcoma was not reported from India or Thailand. However, a frequency
of 52% was reported from Mexico and 19% from Zimbabwe.
-Oral hyperpigmentation was reported from India, Africa, and Mexico.
-Salivary gland disease was reported from Africa and Thailand. These include xerostomia and enlargement of salivary glands.

-Oral candidiasis is the most common opportunistic infection encountered in both adult and pediatric populations in different regions, which is usually effectively managed by antifungal medication.
-I wish the study had discussed special considerations for dental tx based on HIV status and presence of oral lesions.

Tuesday, June 12, 2012

Alcohol Abuse and Dependence: Psychopathology, Medical Management, and Dental Implications

Resident: Elliot Chiu
Title: Alcohol Abuse and Dependence: Psychopathology, Medical Management, and Dental Implications
Author: Arthur H. Friedlander et al.
Journal: JADA 2003
Main Purpose/Methods: Review of the literature from 1995-2001 on alcoholism.
Key Points
-Alcoholism affects 14 million Americans, making it the 3rd most prevalent psychiatric disorder
-Side effects include low-grade hypertension, GI irritation, poor nutrition, and psychiatric issues
-Alcoholics anonymous is a social network that supports abstinence
-Naltrexone is an opioid antagonist that blocks the pleasant feeling or euphoria
-Acamprosate reduces an individual’s craving for alcohol (mechanism remains unknown)
-Disulfiram inhibits acetaldehyde dehydrogenase, resulting in accumulation of acetaldehyde, a toxic product that makes the patient ill
Oral manifestations
-Glossitis, angular cheilosis, gingivitis, salivary gland enlargement
-Excessive bleeding during dental treatment
-Mandible fractures are common from falls or fights
CAGE questionnaire
-“Have you ever felt you should cut down on your drinking?”
-“Have people annoyed you by criticizing your drinking?”
-“Have you ever felt bad or guilty about your drinking?”
-“Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?”
Drug Interactions
-Acetaminophen – liver disease
-Metronidazole – disulfiram-like reaction
-Aspirin/NSAIDS – GI bleeding
Assessment: Good in-depth review of alcohol abuse/dependence. We don't see this often in our patient population, but this may be an issue with the parents or other caretakers.

Tobacco Use by Adolescents: The Role of the Oral Health Professional in Evidence-based Cessation Programs

Department of Pediatric Dentistry
Resident’s Name:                  Jessica Wilson                                    Program:  Lutheran Medical Center - Providence

Title: Tobacco Use by Adolescents: The Role of the Oral Health Professional in Evidence-based Cessation Programs

Author(s): Albert et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s:  2006. 28:2. 177-187.
70% of middle school students and 57% of high school students who use cigarettes live in households with smokers.
According to the authors, children should be screened for smoking risk factors smarting at age 10. Parents should be encouraged to quit smoking. If they cannot quit, they should be encouraged to not smoke around their children, establish smoke-free homes, and monitor their adolescents for smoking signs.
20% of US adults are current smokers. The majority reported starting at adolescence. 31% started regularly before 16 years of age. The gender difference is not significant.
Non-Hispanic Caucasian students reported greater use than African American and Hispanic students.
The use of smokeless tobacco increased in prevalence since the 1990s but has leveled off in the recent years.
Adolescent Addiction:
Youth tobacco use is associated with the following risk factors:
1. Parents who smoke.
2. Friends who smoke (90%)
3. Psychiatric disorders (anxiety, ADHD, substance abuse)
4. Weight concerns
95% of adolescent smokers plan to quit before graduating high school, but 75% will continue smoking.
Tobacco Cessation in the Dental Office:
About half of smokers visit a dentist at least once a year, putting dentists in a good position to intervene.
Brief interventions by dentists that involve simply advising patients to quit have been shown to have a small beneficial effect. A somewhat more intensive intervention is more effective.              
About half of US dentists ask their patients about smoking on a frequent basis, but fewer than 5% provide follow up services. Dentist counseling was found to be positively correlated with adolescent quit attempts.
90% of pediatricians reported counseling 16-18 year olds.
The “5As”:
1. Ask- Identify and document tobacco use at every visit
2. Advise- Urge user to quit in personalized manner
3. Assist- Develop a quit plan
4. Arrange- Follow-up visits and provide encouragement (1sst visit within a few days of cessation attempt)
5. Anticipatory Guidance- Discuss peer and family use and short & long term health risks
-Bupropion SR (sustained release), nicotine gum/inhaler/nasal spray/patch.
-Limited trials have evaluated the effectiveness of pharmacotherapeutics in teenagers. Open-label trials have shown low to moderate abstinence rates in adolescents.

Dental caries of refugee children compared to US children

Resident Name: Sadler
Article Info: Dental caries of refugee children compared to US children
Susan Cote RDH
Pediatrics vol. 114 No. 6 December 2004
Main Purpose: Compare caries experience of recently arrived refugees to children born in the united states

Methods: 224 refugee children between the ages of 6 months and 18 years where examined by a dental hygienist using a pen light and mirror.  Caries was defined a loss of .5mm of tooth structure and brown color lining the walls of the cavity.  Location and number of cavities was noted and was analyzed.
Key Points:
·         Refugees were separated into three groups 1.Africa (Somalia, Liberia, and Sudan) 53.6% 2. Eastern European (Primarily Bosnia) 26.8% and 3. Other (Pakistan, Afghanistan and the middle East) 19.6%. 
·         51.3% of the refugees had some history of caries (treated or untreated) with 48.7% having untreated decay. 
·         40.5% of African children had no dental problems compared to 16.9% of Eastern Europeans. 77.2% of US children have no obvious dental caries
·         Eastern European children were 9.4 times more likely to have untreated decay compared to US children.
·         African American children and African refugees have similar risk of untreated decay. 
·         African children have far fewer untreated caries than eastern European children.  Thoughts on why this could be include a diet low in sugar due the relative poverty in Africa.  This is not necessarily a good thing as many are severely malnourished.  A higher percentage of refugees from urban African communities had caries but the finding was not statistically significant.
·         Pain was present in 11.2% of refugee children while only present in 1.2% of US children
Assessment of Article:  As I read the article it made me think about a lot of the refugee patients we see who many have fewer cavities than patients who are raised in this country.  I do think that it is important to remember that while it is great that they are raised with a diet relatively low in sugar, it may also be severely lacking other vital nutrients.  I was very disappointed that there was no radiographs involved in determining caries and that hygienists made the diagnosis solely by visual inspection.  It was also VERY boring with a huge amount of statistics jargon and was very difficult to read as the group names were continuously repeated.