Wednesday, May 28, 2014

Diet and Caries Associated Bacteria in Severe Early Childhood Caries

Title: Diet and Caries Associated Bacteria in Severe Early Childhood Caries
Authors: Palmer, et al
Journal: J Dent Res 89(11): 1224-1229
Year: 2010
Resident: Hofelich

Key points:

  • frequent consumption of cariogenic foods and bacterial infection are risk factors for ECC
  • authors did a short diet survey that focused on frequency of foods and types of foods and plaque bacteria PCR
  • children aged 2-6 years old, medically healthy, full primary dentition, had not used antibiotics in the last 3 months, and parents signed informed consent
  • 72 severe ECC children
  • 38 caries-free children
  • S-ECC children had higher scores for juice in-between meals, eating frequency, estimated food cariogenicity, and solid-retentive foods
  • Strep mutans, Strep sobrinus, and Bifidobacteria were associated with S-ECC children
  • S. mutans and S. sobrinus were associated with lesion recurrence 
  • S. mutans positive children had higher food cariogenicity scores
Assessment: We ask many of the same questions during our ECC appointments. It is important that we educate the parents as to what causes caries and how to prevent caries.  

Wednesday, May 14, 2014

Lit Review

Gagging and its associations with dental care-related fear, fear or pain and beliefs about treatment
Randall et al
Resident: Avani Khera, DMD

Background: Gagging may be related to dental fear.  It is a behavioral response based on an innate biological mechanism that prevents choking.  

Methods: Participants completed a gagging behavior questionnaire, dental fear survey, and fear of pain questionnaire.

Results: Almost 50% of participants reported gagging on at least one occasion during dental visits.   Patients who gagged more and higher levels of dental fear.

Conclusion:  By targeting dental care-related fear, fear of pain, or negative beliefs about dental care in patient, we may be able to help reduce gagging frequency/intensity making our visits easier.  Before starting procedures in patients who have problems with gagging, a clinician can teach and help patients practice slow, rhythmic breathing; nose breathing; or both, demonstrating that the technique works by encouraging patients to put their fingers or a dental instrument into their mouths during the practice. Reminding and encouraging patients to use such breathing before and during the procedure may be critical. Encouraging pediatric patients who have problems with gagging to wiggle their toes during procedures also can be effective. during bitewing radiography, which yields a viable radiographic image and praise from the technician). In addition, by identifying and systematically confronting a hierarchy of fears and gagging triggers, systematic desensitization can shape the patient’s response and help him or her cope with stress and remain relaxed while experiencing increasingly aversive stimuli

An Analysis of the Phenomenon of increased parental participation during the child’s dental experience

Author: Jimmy R. Pinkham, BS, DDS, MS
Journal of Dentistry for Children (Nov-Dec 1991)

Resident: Anna Abrahamian

Purpose: This article focuses on parental participation and the child’s dental appointment.

Post-WWI, the philosophy amongst pediatric dentists was that parental attendance was not needed, was often counterproductive, and that many dentists were uncomfortable managing children with parents present. Today’s culture is very different – contemporary parents often operate with the parenting paradigm known as “prefigurative” parenting, in which parenting is adjusted daily depending on the needs of the child and this has translated unto a marked increase in the number of parents wanting to be present in the operatory.  There is also a tendency among younger dentists to want parents there as well.

Why do parents want to be present during the visit?
-       Parents argue that their presence will cause their child to behave better, however there is an abundance of anecdotal evidence that children over 3 behave better when parents are not in attendance
-       There is a deep tendency to feel protective of one’s child now versus 40-50 years ago because today’s world does not possess intrasocietal trust  (parents believing that there were certain adults to whom they entrusted their children) and a lack of familiarity with other people and the roles that they play within today’s society have hypertrophied fears of “outside adults.”  This does not necessarily mean that parents intellectually distrust the dentist, but that they are uncomfortable if they cannot visually verify their child’s safety.

Dentists are encouraged to understand that a parent who is determined to be in the operatory has made the decision objectively, even though the source of the decision was an emotional one. Any strategy to convince the parent to not be present will most likely only be effective when the dentist explains what level of management the dentist is prepared to go.  Moreover, the individual dentists must be sure to never describe parental accompaniment as “good versus bad” as this could be potentially litigious and problematic for the professional as a whole.

Pertinent article as we go out into practice – it seems that parent presence in the operatory is much more commonplace.  Interesting that the author states that parent’s make these decisions “objectively even though the source of the decision was…emotional” – these two things seem to not go together.

Using Anticipatory Guidance to Provide Early Dental Intervention

Using Anticipatory Guidance to Provide Early Dental Intervention

Resident: Robyn Hofelich
Title: Using Anticipatory Guidance to Provide Early Dental Intervention 
Authors: AJ Nowak and PS Casamassimo
Journal: Journal of American Dental Association. 1995. 126(8):1156-1163

Main Purpose: To discuss why preventive dental care for children must begin earlier, go beyond traditional caries management and incorporate developmental milestones and functional considerations so that each child’s individual risk for oral conditions is addressed.

Key Points:
Previously, dental visits for children began when the child was 3 years old. At this age a child could cooperate in restorative care, was about to begin school and had all the primary teeth. Early identification and appropriate management of dental problems such as caries can minimize intervention and prevent the occurrence of negative, often costly sequelae.
- Anticipatory guidance is the process of providing practical, developmentally appropriate health information about children to their parents in anticipation of significant physical, emotional and psychological milestones.
- The current recommendations by the American Academy of Pediatric Dentistry for anticipatory guidance in pediatric dental care includes areas such as oral development, fluoride adequacy, oral hygiene and health, habits, nutrition and diet, and injury prevention
- Parents are extremely satisfied with the interaction that this approach brings, and they enjoy the functional approach to education that deals with specific events in their own family.

This article is one of the first articles advocating early intervention in pediatric dentistry. This approach is an excellent way to educate parents about upcoming events in their children’s lives and to prevent future problems. 

Review of Monitors and Monitoring During Sedation with Emphasis on Clinical Applications

Resident: Todd Bushman
Title: Review of Monitors and Monitoring During Sedation with Emphasis on Clinical Applications
Journal: Pediatric Dentistry 1995
Author: Stephen Wilson

Pulse Oximetry
-Continually measures indirectly O2 saturation and heart rate
-Sensor contains 2 elements: one emits light in red and infrared wavelengths and the other detects light transmission through tissue
-Oxygenated hemoglobin absorbs more red while deoxygenated hemoglobin absorbs more infrared wavelengths
-Signal errors may be caused by: crying, cold limbs, nail polishes, profound tissue pigmentation in some blacks

Blood Pressure Cuffs
-A combative or uncooperative child would be expected to have an elevated BP, which tends to decrease to normal values as the child becomes sedated
-In dosages designed to produce conscious sedation, most sedative agents do not cause significant clinical changes in BP

-Measure expired CO2 concentrations with infrared absorption technology
-Normal CO2 concentrations in children range from 33-40mm Hg
-Most have an alarm to indicate an obstruction

Precordial Stethoscopes
-Can obtain heart, respiratory, GI, and joint sounds
-Placement of the stethoscope can cause breathing sounds or cardiac sounds to be predominant
-During sedations, airway sounds are more important

The association between antibiotics usage in early childhood and early childhood carries.

Resident: Jeff Higbee

Article: The association between antibiotics usage in early childhood and early childhood carries.

Journal: Pediatr Dent (2009) 31(1): 31-37.

Author: Alaki, S. M., Sumer, M. Burt, B. a., and Garetz, S. L.


Purpose: The objectives of this study were to learn if the intake of systemic antibiotics during the first year of age (period of primary teeth development) was associated with an increased risk for early childhood caries during the following years; and after the first year of age (following the formation of primary teeth) was associated with a lower risk for early childhood caries during the following years.


Conclusions: Children who used systemic antibiotics during the first year of age had a significantly greater risk for early childhood caries (ECC) during follow-up compared to children who did not use antibiotics. After the first year of life, only children who used systemic antibiotics at 13 to 18 months old showed a significant increase in the risk of ECC. A child's racial background was a determining factor in the association between antibiotic intake and ECC.


Assessment: It is important to know the med hx in our patients and to know if they have had any significant infections during their early years of life requiring abx. 

Child Abuse and Neglect: Current Concepts

Child Abuse and Neglect: Current Concepts.
American Board Article. Issue 332(21), 1995.
Author: Wissow, LS.
Resident: Margaret Maclin

Purpose: To review diagnostic and therapeutic issues posed by child abuse and neglect.

Definitions and Epidimiolic Features:
- Child maltreatment is intentional harm or a threat of harm to a child by someone acting in the role of caretaker, even if only for a short time.
- Maltreatment is divided into 4 groups: physical, sexual, emotional, and neglect.
- Negrlect is the most common of the 4 types.
- Physical abuse involves inflicting bodily injury through excessive force or forcing a child to engage in physically harmful activity.
- Emotional abuse is coercive, demeaning, or overly distant behavior by a parent or caretaker that interferes with a child's normal social or phycological development.
- Sexual abuse includes inappropriate exposure of a child to sexual acts or materials, the passive use of children as sexual stimuli for adults, and actual sexual contact between children and older people.
- Child maltreatment occurs across all SES groups.
- Incedence of sexual abuse is found in all SES groups evenly, Negrlect and physical abuse are found more often with increased level of poverty.
- Child abuse and neglect normally occur together with other forms of abuse in the home, such as spousal battery and violence between siblings.
- On average about 1.4 million US children under 18 (2.3%) ungero some form of child maltreatment every year.
- Though 80% of the deaths resulting from maltreatment occur in children under the age of 5, the incidence of physical and emotional abuse has been shown to increase with age.
- Social and emotional handicaps are the most serious long-term consequences of maltreatment.
- Physically abused children are generally more aggressive with their peers than those who have not been abused, have more troubled interpersonal relationships, and have more depress and aggressive symptoms and affective disorders.
- Sexuall abused kids also have increased frequency of anxiety disorders and problems with sex roles and sexual functioning.
- As adults, children that have been abused suffer two to three times as much from drug abuse and depression as members of the general population.
- This is reports to be due to changes, mediated by abuse, in the neuroendocrine systems influencing arousal, the pain threshold, learning and growth.

Detecting Abuse and Neglect:
- Child maltreatment is difficult to detect.
- Child care providers can detect maltreatment by creating an atmosphere that encourages disclosure and by learning to ask directly and empathetically whether maltreatment is taking place.
- A good history, psychological and medical from parent and child is key.

- One approach would be to view the presenting form of maltreatment as only a symptom of underlying disorders that must be uncovered before a long-term therapeutic plan can be divided.
- Treatment may involve working with the family as a init and working separately with individual members.
- Formal and informal tx teams usually include social workers, mental health professionals, attorneys and community aides, in addition to medical personnel.
- Tx appears not to work that well with adults who abuse their children. 30% were found to continue abusing their children even during tx.
- Positive results have been shown for some education programs for physically abusive and neglectful parents and preventive home visits to young mothers who otherwise appear to be at risk for abusing their children. (**How is this allowed? Stereotype women who look like child abusers?**)
- Tx results in children also appear to be mixed. Foster care, which would normally guarantee safety from the physical abuse might result in permanent separation of the child from the family, and this to a child may be more traumatic than being left with his abusive family.
- Family-preservation programs have thus become more popular, since they keep the child in the home while changing the home environment for the better.

Wednesday, May 7, 2014

The Appropriate use of physical restraint: considerations

The Appropriate use of physical restraint: considerations
Charlotte Connick, RDH, MS. et all.
Journal of Dentistry for Children July-August 2000
Resident: Margaret Maclin

Background: There has been a growing concern regarding the use of physical restraint on patient with developmental disability, especially because behavior problems are a major concern in the long-term care population.  Current federal Law define restraint as "any manual method, physical, or mechanical device, or material, or equipment attached or adjacent to the resident's body, which in the individual cannot remove easily and restricts freedom of movement or normal access to one's body: The definition can range from the simple prevention of a patient's hand interfering with treatment to a complete immobilization of the body in a restraining device. Several cases were listed that reviewed the use of restraint and highlighted some of the important ethical and legal issues associated with the use of restrains to provide dental care for uncooperative patients. 

Conclusion: Despite federal and state guidelines, the appropriation of restrains is still not clear. The Federation of Special Care Organization in Dentistry states, that the federal government, states and national advocacy organizations have reached some agreement on the following concepts. 
- Restrains should be used only when absolutely necessary.
- When deemed necessary the least restrictive alternative should be chosen.
- Restrains should not be used as punishment
- Restrains should not be used solely for the convenience of staff. 
- Staff should closely monitor its use.

 Assessment: I think this is really useful especially since we have just started with sedations and the use of a papoose is not always necessary but often when it is necessary it needs to already be in place. It gives lots of guidelines for us to use when making our own decisions about how and when we will use restraints in our practices.

Influences on Children's Oral Health: A Conceptual Model

Influences on Children's Oral Health: A Conceptual Model

Author: Fisher- Owens, et al
Journal: Pediatrics
Year: 2007
Resident: Hofelich

Purpose: Caries is the most common chronic disease of childhood. The purpose was to present a more encompassing conceptual model of the influences on children's oral health.

Methods: The conceptual model was derived from the population health and social epidemiology fields. It is based on a comprehensive review of major population and oral health literature.

Multilevel conceptual model of influence on oral health outcomes

5 key domains of determinants of oral health
-biological and genetic factors
-social environment
-physical environment
-health behaviors
-dental and medical care

The model also includes the aspect of time, recognizing the evolution of oral health diseases and influences on the child-host over time.

Conclusions: Children's oral health has traditionally focused on biologic and environmental factors with poor predictive results. By applying a multivariate statistical methodology in overall public health, this methodology applies an appropriate complex, yet manageable, model to children's oral health will result in improvements in predictive power.

Tuesday, May 6, 2014

Detection Activity Assessment and Diagnosis of Dental Caries Lesions

Braga, Mariana M., et al.
Dent Clin N Am 54 (2010) 479-493
Resident: Anna Abrahamian, DMD

Caries examination and evaluation should not be limited to physical criteria like size, depth, and presence/absence of cavitation (caries lesion detection). Rather, the diagnosis of caries should take these elements together with examination of  otheretiologic factors like oral hygiene (OH), count of cariogenic microorganisms in plaque and saliva, use of fluoride, sugar intake, and socioeconomic factors.

Visual Inspection:
-       High specificity (proportion of sound sites correctly identified) but low sensitivity (proportion of carious sites correctly identified) because of it’s subjective nature.
-       Use of detailed visual indices like the International and Caries Detection Assessment System (ICDAS) may improve sensitivity by identifying stages in the caries disease process
o   ICDAS in primary teeth cannot distinguish accurately between lesions related to the outer or inner half of the enamel (because primary enamel is thinner).
o   Nyvad’s System: scoring system (0-9) to identify depth of caries visually

Other Methods:
-       BW radiographs improve sensitivity and specificity of caries detection (from 0.63 to 0.9); monitoring is more reliable and accurate.
-       Transillumination: fiber optic transillumination (FOTI) makes carious enamel and dentin appear as shadows; not quantitative, treatment decisions depend on the dentist’s interpretation.
-       Electronic Caries Monitor (ECM): uses alternating current and measures the bulk resistance of tooth tissue; porosity of caries lesions is filled with fluids with high concentration of ions from the oral environment, and this more porous tissue decreases electrical resistance more than sound tissue (high sensitivity, low specificity).
-       Fluorescence: DIAGNOdent is a a diode laser fluorescence device that emits a red light that is absorbed by bacterial by-products (porphyrins) that partially re-emit light as near-infrared fluorescence – device captures this and translates it into a number (0-99); the higher the number, the deeper the caries.

AAPD Article #8

Building caries risk assessment models for children.
Gao, X. L., et al.  J Dent Res
 Resident: Avani Khera

Introduction: Caries is the most common chronic childhood disease and a major financial burden on society. Evidence has linked ECC with caries in the permanent dentition, therefore, early and accurate selection of high risk preschoolers is important for cost-effective caries control.

Purpose:  The purpose of this population-based prospective study was to identify caries risk factors, indicators, and protective factors to develop and validate bio psychosocial caries risk assessment models for preschoolers.

1.    Questionaire survey: A parent administered questionnaire collected information on the childs demographic background, socio-economic status, children’s oral health practice, systemic diseases, and parental knowledge and attitudes on oral health.
2.   Caries Examination and Oral Hygiene Evaluation: Child was examined by 1 examiner and given a DMFT score.
3.   Biological Tests:  The plaque pH at all 6 sites of the tooth was measured
4.   Follow up Caries Status:  The caries exam was repeated after 12 mo’s with the same criteria and proceudres (a dmft score was calculated).

Results: The chance of caries risk increased with prolonged breastfeeding, age, bedtime feeding, frequent snacks, and past caries experience. 

Discussion: A useful risk assessment program should be one with high simplicity, sensitivity, and specificity.   With a questionnaire and clinical examination, potential high-risk children can be identified for early treatment and intervention.