Wednesday, October 29, 2014

Parent’s Presence in the Operatory During Their Child’s Dental Visit: A Person-Environmental Fit Analysis of Parent’s Responses

Title: Parent’s Presence in the Operatory During Their Child’s Dental Visit: A Person-Environmental Fit Analysis of Parent’s Responses
Author: Kim et al.
Journal: Pediatric Dentistry Sept/Oct 12

Purpose: The purpose of this study was to explore whether parents’ satisfaction with their child’s treatment and their attitudes concerning the dental visit are affected by the fit between their desire to be present/absent during their child’s dental tx and whether they were actually present/absent.

Background: Parental presence during medical and dental procedures has long been a controversial topic.  The controversy focuses on how the parents’ presence/absence affects children’s, providers’, and parents’ responses to the treatment.  The guidelines of the AAPD, include parental presence or absence as a method to help establish effective dentist-child communication during dental tx.

Methods: Survey data were collected with paper-pencil surveys from 239 parents/guardians of regularly scheduled child patients at a pediatric dental clinic at Midwestern dental school; 185 of these parents fell into the consistent condition (“wanted to be with child and were with child” or “did not want to be with child and were not with child”) and 38 were in the inconsistent condition.

Materials: Parent baseline survey included questions about the patients oral health and dental anxiety and the parents oral health, dental fear and preferences concerning accompanying their child into the operatory. Parents were asked to reflect on whether they wanted to be/not to be with their child in the operatory, whether they actually were with their child, and how much they wished they had been with their child. In addition, six questions were asked to indicate 1. How satisfied they had been with the visit 2. How comfortable they had been 3. How friendly the dentist had been 4. How well the dentist had explained what would be done during the visit 5. How much they trusted the dentist and 6 how much they had learned about making sure that the child would have healthy teeth.

Results: The central objective was to determine whether the parent’s responses to their child’s dental visit differed as a function of whether they had encountered a consistent vs inconsistent situation concerning the fit between their own wishes and the actual visit.  The parents’ own responses to their child’s visits showed that the parents in the consistent condition were significantly more satisfied with the child’s dental care than the parents in the inconsistent group. The older the parents were, the more they wanted to accompany the child into the operatory.

Conclusion: Based on the study’s results, the following conclusions can be made: 1. Compared to parents whose desire was not matched with the actual event, parents desire to be present/absent during their child’s dental visit matched the actual event: a. were more satisfied with their child’s dental appointment b. had a more positive attitude toward the dentist and the dental visit and c. had a more positive perception of their child’s response to the appointment. 2.Concerning the effects of the child and parent background and dental tx-related characteristics, the younger the child is, the older the parents are, and the fewer previous dental appointments and treatments a child had, the more the parents wanted to accompany their child.

Biological mechanisms of early childhood caries

Biological mechanisms of early childhood caries 
Authors: Seow WK
Community Dentistry and Oral Epidemiology1998
Resident: Margaret Maclin

To review the biological mechanisms involved in ECC and to screen for factors which might provide clues to its complex etiology

Key Points
Dental plaque
  • First stage in plaque formation involves the deposition on the tooth surface of an acquired pellicle which plays significant roles in microbial colonization and dental caries
  • There is a progressive shift from mainly aerobic and facultatively anaerobic species in the early stages to more facultatively anaerobic and anaerobic species after 9 days. 
Acid production in dental plaque
  • When fermentable carbohydrates are present, lactate is mainly produced, which coincides with a pH drop in plaque
Virulence of Mutans Streptococci
  • MS produce large amounts of acid, particularly lactic acid, which are potent in driving tooth demineralization
  • The acid tolerance of MS is extremely high, allowing colonization and persistence under cariogenic conditions
Colonization of MS in dental plaque
  • In the absence of sucrose, other bacteria such as S. sanguis have a higher affinity for pellicle-coated teeth than MS
  • In the absence of exogenous carbohydrates, MS contain low levels of intracellular polysaccharide, and there is little substrate for substantial bacterial growth and accumulation
  • In the presence of sucrose, MS irreversibly adhere to the pellicle through the synthesis of glucans mediated by glucosyltransferases produced by the bacteria
Establishment of MS in infants
  • Most studies including predentate children show that MS are usually not cultured from the oral cavity prior to the eruption of teeth 
  • Infection rate of MS increases with age, as well as the number of teeth present in the infants’ mouth
Transmission of MS
  • A minimum infective dose of MS is necessary for implantation, which is enhanced by repeated inoculation
Immunological factors
  • Secretory IgA may inhibit bacterial adherence and/or agglutination, as well as neutralization of bacterial enzymes, but there is little evidence that naturally occuring IgA antibodies protect against dental caries
  • Although controlled animal studies have reported less dental caries in those which suckled on breast milk containing antibodies to MS, the protection by passively transferred IgA through breast-feeding has not been verified in humans
Tooth maturation and defects
  • Period immediately after eruption and prior to final maturation is when the tooth is most susceptible to caries
Association of enamel hypoplasia with dental caries
  • Surface irregularities such as pits and grooves predispose to plaque retention, increased MS colonization, and possibly, decreased clearance of carbohydrates. Alteration or loss of the enamel surface due to enamel hypoplasia predispose a tooth to increased caries risk

General cariogenicity of sugars
  • Sucrose is the only substrate used for bacterial generation of plaque dextrans which are essential for bacterial adherence
  • Sucrose, glucose and fructose found in fruit juices and vitamin C drinks as well as in solids are probably the main sugars associated with infant caries
Frequency of consumption
  • Increased frequency of eating sucrose increases the acidity of plaque, and enhances the establishment and dominance of the aciduric MS
Oral clearance of carbohydrates
  • The low salivary flow during sleep decreases oral clearance of the sugars and increases the length of contact time between plaque and substrates, thus increasing the cariogenicity of the substrate significantly
  • Clearance of glucose is slowest on the labial surfaces of the maxillary incisors and the buccal surfaces of the mandibular molars
Cariogenicity of foods
  • There is no evidence to suggest that bovine milk is cariogenic. 
  • Human breast milk has a lower mineral content, higher concentration of lactose, and less protein, but these differences are insignificant in terms of cariogenicity
  • Even at very low concentrations, fluoride can affect the demineralizing process in a carious lesion by decreasing the rate of subsurface dissolution and enhancing the deposition of fluoridated apatite in the surface zone. 

Clinical Complications in the Revascularization of Immature Necrotic Permanent Teeth

Authors: Basma Dabbagh, DMD, et al

Journal: Pediatric Dentistry, V 34/ No, Sept/Oct 2012

Purpose: To report the technique used to treat immature necrotic permanent teeth, the problems encountered during treatment and follow-up, and some modifications made to the treatment procedure to solve the problems.

Background: The treatment of necrotic immature permanent teeth has always presented many challenges as the roots are incomplete, thin, divergent, have fragile walls and have wide open apices. The ideal treatment for an immature necrosed tooth is to regenerate a healthy pulp-dentin complex that allows for the maturation of the root.


Fourteen children needing apexification treatment with a total of 18 immature teeth with odontogenic infections were selected. The first step was to standardize the radiographic technique by securing the same angulating with a bite registration. The pulp of the teeth were then accessed with a local anesthetic, rubber dam, irrigation of NaOCL; the canals were not instrumented in order to prevent the formation of a smear layer that would alter the dentinal walls. A triple antibiotic paste containing minocycline, ciproflaxin, and metronidazole was then inserted into the canals. The teeth were then monitored for signs and symptoms of infection. If everything was within normal limits, the canals were accessed again and were irrigated with NaOCl. A sterile file was then placed beyond the apex to provoke bleeding. Once the blood reached the CEJ, it was left untouched for 15 minutes to allow for a clot to form. Three millimeters of MTA barrier was then placed over the clot. All of the patients then returned for follow-up at 1, 2, 3, 6, 12, 18, and 24 months.

The following problems were encountered using the protocol above: discoloration of the crown of the tooth due to minocycline use, inability to consistently produce an ideal blood clot to the CEJ, difficulty in controlling placement of the MTA, and root elongation was not noticed until the 6 month follow up visit.

In order to address these problems, the following changes were made:

1.)  Minocycline was replaced by ceflacor (a second generation cephalosporin), which resolved the staining problem and maintained control of the dental infections.
2.)  Anesthetic without vasoconstrictor was given in order promote bleeding in the canal; instrumentation of the canal was performed with a bent endodontic file that went past the apex.
3.)  A collagen matrix above the blood clot allowed controlled placement of the MTA in order to prevent the MTA from collapsing into the canal.
4.)  Parents were informed that root formation was a lengthy process and that results were notable after 6 months following the treatment.

Conclusion: Further research is needed pertaining the different antibiotics, cements, and matrices that can be used in dental pulp-tissue engineering.

Oral Manifestations as First Clinical Sign of Acute Myeloid Leukemia: Report of a Case

Article Title: Oral Manifestations as First Clinical Sign of Acute Myeloid Leukemia: Report of a Case
Author: Ester Sepulveda, DDS et al.
Date: Pediatric Dentistry, Volume 34 No. 5, Sept/Oct 2012, pgs. 418-421

Major Topic:  Oral manifestation of Acute Myeloid Leukemia

Main Purpose:  Report a case of persistent and severe hemorrhage after tooth extraction and generalized gingival enlargement over a short period of time.

Introduction:  Leukemia:
·      most frequent malignant neoplasm in children 15 years or younger
·      Hematological disorder – proliferation of immature white cells, infltrate the bone marrow and other organs
·      Oral manifestation have been observed in 15-90% of patient, most commonly in acute cases
·      Oral lesions:
o   Primary lesions: infiltration of the oral tissues by malignant cells (frequently in acute myeloid leukemia)
o   Secondary lesions: those associated with anemia (mucosal pallor, delayed wound healing), granulocytopenia (increased susceptibility to fungal, bacterial, and viral infections, neutropenic ulcers),  Thrombocytopenia (increased hemorrhagic tendency)
o   Tertiary lesions: related to myelosupressive and immunosuppressive therapy, direct/indirect cytotoxicity

Case description:  6 y/o male referred to Oncohemathology Service of Regional Hospital, Concepcion, Chile. 
·      Physical exam: extremely pale, fever, malaise
·      Intraoral exam: sever gingival hemorrhage, generalized gingival enlargement, petechiae, ecchymoses (hard palate) Multiple lymphadenopathies
·      Patient had an extraction 2 weeks prior of a loose primary tooth, that required sutures to control bleeding at the time of extraction
·      ER visit one week after extraction due to hemorrhage of the extraction site; sutures and oral tranexamic acid for 1 week
o   At the same time diagnosis of tonsillitis made and patient was treated with benzathine benzylpenicillin, referral was made to the regional hospital for presumptive diagnosis of leukemia
·      Blood work was completed (tables below), cardiology was normal, liver was normal sixe, thoracic radiograph was normal, abdominal echotomograph showed splenomegaly of 10.5cm, bone marrow aspirate confirmed diagnosis of acute myeloid leukemia type M3 or acute promyelocytic leukemia
·      Patient underwent treatment and was currently under observation
o   Oral compilations:  grade IV mucositis (very painful ulcerative lesions covered by fibrinous exudate)
o   Debilitating patient from oral intake and served as a site for potential local infection
·      Brushing was suspended when platelets were below 30,000 cells/ml3
·      Gingival enlargement disappeared 15 days after chemotherapy treatment was completed
·      Other preventive measures:  chlorhexidine 0.12% mouthwashes twice a day and micronazole gel 20mg/g (for fungal infections)

Discussion:  Gingival enlargement/ bleeding is seen in:
·      Chronic inflammatory process produced by dental plaque in gingivitis or other hyperplasic lesions
·      Side effect of medications: (collection of extracellular matrix within the gingival connective tissue)
o   Antiepileptic (phenytoin)
o   Immunosuppressive agents (cyclosporine A)
o   Calcium channel blockers for cardiovascular disease (dihydrophyridines like nifedipine, diltiazem, and verapamil)
·      Infiltration of gingival tissue by neoplastic cells like leukemia cells.

Conclusion:  As pediatric dentist we have to be aware of alternative reasons for gingival enlargement/bleeding especially in patients that display other symptoms.

Radiographic Changes Associated with Pulp Infection in Primary Incisor Roots and in Their Developing Permanent Dental Follicles

Authors: Ashkenazi et al
Journal: Pediatric Dentistry Vol 34 No 5 Sept/Oct 2012

Purpose: Early diagnosis and treatment of pulp infection in primary incisors are important for preventing systemic infection and damage to the permanent tooth bud. This study identified radiographic changes associated with pulp infection in primary incisor roots and their developing dental follicles.

Pulp infection in primary teeth may cause:

  • alterations in tooth eruption 
  • induce changes in the development of successor permanent tooth buds
  • hypoplasia
  • morphological alteration of the dental crown
  • total arrest of radicular formation
Developmental disturbances are characterized by color changes with or without defects in the enamel. They are due to the absence of hard tissue between the primary tooth apex and the permanent dental bud. 

  • retrospective case-control study done at Tel Aviv University, Israel
  • records of children from 2005-2008
  • oblique occlusal radiographs of 102 primary maxillary incisors with sinus tracts were compared to 390 radiographs of incisors from healthy same-age children
  • maximum age was 5 yo for central incisors and 6.5 yo for lateral incisors
  • radiographs were analyzed for changes in the dental sac
    • enlargement more than 2 mm compared to adjacent intact tooth
    • radiolucency of the dental sac that was increased more than that of the pulp of the primary incisor
    • loss of or incomplete lamina dura 
  • also classified as:
    • no pathological changes
    • obliteration of the dental pulp
    • having pathologic changes in the roots of primary teeth
    • presence of surface root resorption
    • inflammatory external resorption
    • internal root resorption
    • cessation of pulp chamber development
  • sinus tract was significantly more common in central than lateral incisors
  • teeth subjected to trauma had significantly more sinus tracts
  • sinus tracts were significantly more common in teeth with deep caries
  • teeth with external inflammatory resorption had significantly more sinus tracts
  • sinus tracts were significantly more prevalent in teeth with pulp necrosis or internal inflammatory root resorption
  • teeth with increased radiolucency of the dental sac had significantly more sinus tracts than teeth without, same for loss of lamina dura
  • Primary incisors with radiographic evidence of internal or external inflammatory root resorption are statistically associated with presence of a sinus tract and therefore should be treated immediately by RCT or EXT
  • primary incisors in which there is loss of discontinuity of the lamina dura and increased radiolucency of the dental sac of the corresponding permanent tooth bud are statistically associated with presence of a sinus tract and therefore should be treated immediately by RCT or EXT
  • primary incisors with deep caries or with cessation of pulp chamber due to pulp necrosis, but without any other pathologic signs, are at high risk for infection and therefore should be followed by periodic radiographic examination to exclude development of infection
  • primary incisors in which there is enlargement of the dental sac of the corresponding permanent tooth do not necessitate operative intervention, but should be followed by periodic radiographic examination to exclude development of infection


The Safety of Sedation for Overweight/Obese Children in the Dental Setting

Anna Abrahamian
October 29, 2014

Article Title: The Safety of Sedation for Overweight/Obese Children in the Dental Setting

Author: Jina Kang, DMD, MS, et al.

Journal: Pediatric Dentistry, V 34, No 5

Date: Sep-Oct 2012

Major Topic: Sedation

Main Purpose:  The goal of this study was to examine childhood overweight/obesity as a risk factor for adverse events during sedation for dental procedures.

The CDC has categorized obesity as an epidemic. The prevalence of obesity in adults in the US has more than doubled since the 1980s and currently 32% of children and adolescents in the US are overweight or obese.

BMI (calculated from height and weight) is a reliable indicator for body fat for most people. For children, the distribution of BMI changes with age, just as weight and height distribution change.  Because of this, the CDC defined 4 categories for BMI in children: 1) underweight (<5th percentile), 2) healthy weight (5-85th percentile), 3) overweight (85th-95th percentile), and obese (>95th percentile).

With respect to general anesthesia, studies have shown that increased deposition of adipose tissue in the neck and pharynx caused narrowing of the airway and increasing severity for obstructive sleep apnea (OSA). Other studies have shown that excess weight added to the thoracic cage and abdomen can further restrict ventilation – this causes a reduction in functional residual capacity and higher metabolic consumption, all of which may result in faster desaturation versus patient of normal weight.

With respect to sedation, adverse events such as respiratory depression are a major complicating factor in obese children.  Other adverse events reported frequently include: nausea/vomiting; apnea; desaturation; and prolonged sedation.

The AAPD published the most recent guidelines for pediatric sedation in 2006. Although they emphasize complications and the importance of airway management they are silent concerning overweight/obese children and there is not suggestion to obtain a BMI and the guidelines offer no recommendations or safety related to weight.

This was a cross-sectional, retrospective study that included 17 years of data (1999-2009) and 510 patients that underwent sedation. The outcome variables were desaturation, nausea/vomiting, prolonged sedation, and true apnea. The major explanatory variables were weight percentiles and BMI percentiles. The children were grouped into 2 weight categories: 1) <85th percentile, 2)>85th percentile.

431 (86%) of the 510 patients experienced no adverse events. 73 (14%) experienced one or more adverse events. BMI data was available for a cohort of these patient (103).  Patients who experienced one or more adverse events had higher mean weights and BMI percentiles, but these differences were not shown to be statistically significant.


These findings suggest that childhood overweight/obesity may be associated with adverse events during sedation for dental procedures.  The authors suggest that these findings should serve as a point of departure for further research and that in the interim, dentists should obtain pre-sedation weight and height and calculate BMI prior to sedation.


Author: Arthur J. Nowak
Journal: J Am Dent Assoc. 2002
Resident: Avani Khera, DMD

Main purpose: Paper describing the concept of a dental home and its advantages

Key points:
   Concept of a medical home was proposed in 1992
   Observations and empirical evidence dating back 20 years supported the concept of the medical home and that it was associated with better outcomes for patients
   At the time of publishing the concept of a dental home could only be supported by expert opinion and observation.  However, if a dental home can be similar to access to care then significant evidence exists that supports the concept.
   Use of a dental home will increase the appropriateness and timeliness of care
   Historically, many first visits to a dental setting were because of trauma or emergencies which often times occurred in an emergency room setting.  This was costly and often unnecessary.
   Having a dental home establishes a relationship between the patient and the dentist and also allows for preventive care and anticipatory guidance
   Characteristics of dental home should be: Accessible, Family-Centered, Continuous, Comprehensive, Coordinated, Compassionate, Culturally Competent.
   A knowledge of the family will help to anticipate caries risk and recommend personalized care and preventive treatments

   The dental home should be the place where specialized care is coordinated.