Wednesday, September 28, 2016

A review of the diagnosis and management of impacted Maxillary Canines

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Amir Yavari, DDS (Mentor: Dr. Hencler)                                              Date: 09/28/2016
Article Title: A review of the diagnosis and management of impacted Maxillary Canines
Author(s): Marisela Bedoya, Jae Hyun Park
Journal: JADA
Date: 2009
Major Topic: Growth and Development and Orthodontics
Main Purpose: This was a literature review regarding the clinical and radiographic diagnoses of impacted maxillary canines, as well as the interceptive treatment (including surgical and orthodontic management) used to prevent or properly treat impacted canines.

Upper canines 2nd most common impacted teeth (1st is 3rd molar) + 2x in females + 2% of population
Of all patients w/ impacted canines 8% bilateral; 1/3rd labial and 2/3rd palatal

Types of Studies Reviewed: 
The authors reviewed clinical and radiographic studies, literature reviews and case reports.  They selected only studies that pertained to the prevalence, etiology and diagnosis of impacted maxillary canines, as well as the most recent studies regarding surgical and orthodontic techniques for the proper management of impacted maxillary canines.

Ericson and Kurol: Extracting primary canines before 11yo may normalize erupting position of permanent canine in 91% of cases where crown is distal to midline of later incisor; decreases to 64% if crown is mesial to midline of lateral.
Impacted canines can be detected at an early age, and clinicians might be able to prevent them by means of proper clinical diagnosis, radiographic evaluation and timely interceptive treatment.  
Management of Impacted Canines:
  v Labially impaction: Gingivectomy, apically positioned flap, and using closed eruption techniques
  v Palataly impaction: Closed flap, open eruption, open window eruption, tunnel traction
Orthodontic techniques: Cantilever system, double arch wire mechanics, TADs, Easy way coil system, Auxiliary spring, K-9 Spring
With early detection, timely interception, and well-managed surgical and orthodontic treatment impacted maxillary canines can be erupted and guided to an appropriate location in the dental arch.
-       Useful and important article because we see many of these patients when the canines are forming. How we treat them while they are young greatly impacts the future development of their teeth.  We have the ability to intervene and avoid future complications
-       What is the etiology? Tooth size arch size discrepancy (crowding), failure of the primary canine root resorption, early loss of primary canine, ankylosis, cyst or neoplasm
-       Early diagnosis à buccal/palatal impaction are very important in the final outcome

Assessment of Article:  Level of Evidence: Level I

Dental fear/anxiety and dental behavior management problems in children and adolescents: a review of prevalence and concomitant psychological factors.

Dental fear/anxiety and dental behavior management problems in children and adolescents: a review of prevalence and concomitant psychological factors.

Resident’s Name: Semantha Charles      Date: 09/28/16
Article Title: Dental fear/anxiety and dental behavior management
problems in children and adolescents: a review of prevalence
and concomitant psychological factors.
Authors: KLINGBERG et al.
Journal: International Journal of Paediatric Dentistry
Date: 2007
Major Topic: Dental Fear
Type of Article: Textbook - Review

Main Purpose: Evaluate prevalence of dental fear and anxiety (DFA) and dental behavior management problems (DBMP) in children and adolescents, and their relationships to age, sex, general anxiety, temperament, and general behavioral problems.

Key Points/Summary:
  • Mild fear and anxiety are expected experiences' consistent with normal development, but they become a concern and potentially in need of treatment when the fear or anxiety is disproportionate to the actual threat, and daily functioning becomes impaired.
  • DFA and DBMP are relatively common encounters in the dental setting, affecting approximately 9% of children in normal populations in Australia, Canada, Europe, and the USA.
  • DBMP seems to decline with age, while the relationship between age and DFA is more complicated.
  • Both DFA and DBMP seem to be more frequent in girls and to be related to general fear and internalizing and externalizing behavioral problems even though these relationships are not clear-cut.
  • Temperamental factors are related to both DFA and DBMP but with different temperamental characteristics, while general behavior problems mainly correlate with DBMP.
  • Pain and perceived lack of control were outside of the scope of this review.

The Communication of Pain in Pediatric dentistry

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Nicholas Paquin                                                                           Date: 09/28/2016
Mentor: Dr. S. Sapir

Article Title: The Communication of Pain in Pediatric dentistry
Author(s): Versloot and Craig
Journal: Eur Arch of paediatric dentistry
Date: 2009
Major Topic: Pain assessment in children
Type of Article:  Literature review
Main Purpose: To improve the process of pain assessment in children to be more accurate to deliver better care.
Key Points: (2 lines Max): When dealing with younger children non-verbal communication is critical to avoid failure in delivering needed care.  Awareness of dental anxiety, previous experience, parents demeanor and ensuring adequate anesthesia are crucial.
-        Acute pain is highly subjective and includes complex thoughts and feelings as well as sensory events.
-        It’s primitive role is to warn children of possible danger and motivates escape and avoidance to limit possible additional injury.
-        There is striking individual differences in how people react to tissue insult: Some very stoic and others are hysterical. Child who are not reactive pose a risk of pain by not receiving necessary care, ie adequate analgesia. The opposite can happen by a guarded provider being concerned a child will over react and become problematic during treatment.
-        A prevalence of 9% of dental fear and anxiety among children and adolescence with the strongest fear associated with injections. Patients’ fears may be acquired through vicarious experiences (parents or siblings), however personal experience is the most common source of dental fear.
-        The presence of a parent and the parents’ level of anxiety concerning the child’s treatment is important. Parental presence is often comforting to the child, but some children will show greater distress or pain behaviors when the parent is present. Parents who are upset/nervous are likely to be disruptive; parents who are comfortable and relaxed are likely to instigate the same response in their children.
-        Previous experience has great influence on how subsequent treatment is experienced. A positive first experience can positively influence the expectation of future appointments.
-        Coping strategies: 4-7 – are generally behaviorally oriented and may need promting by adults.
-                            Age 8-10 – children begin to supplement, but not replace, behavioral stretegies used at                     younger ages with increasing cognitive strategies.
-                             Age 11+ - children tend to use more cognitively oriented strategies and more self control when dealing with a stressor.
-        Pain assessment: at 4 years old self reporting may become useful and can use the faces scale. A study showed that 40% of the children asked to report on the pain during LA gave a different score to the dentist than to the parent. And 28% over reporting to the parent

1- I agree with your remarks. Important to know article (also for the boards!).

Managing Behavior of the Cooperative Preschool Child

Department of Pediatric Dentistry

Lutheran Medical Center


Resident’s Name: John Diune                        Mentor’s Name: Dr. Kiang                Date: 9/28/2016

Article Title: Managing Behavior of the Cooperative Preschool Child
Author(s): Jimmy R. Pinkham, BS, DDS, MS
Journal: Dental Clinics of North America
Date: Oct 1995
Major Topic: Behavior management, personality development
Type of Article: Expert opinion
Main Purpose: Share expertise regarding managing behavior of cooperative preschool child
Key Points: (2 lines Max): Explain the need for and importance of linguistic domain of behavior management of the preschool child
Keypoint: Communication and coaching skills are absolutely essential in dentistry for the preschooler.
Without good communication, other strategies outside the domain of language would need to be utilized.
As a general rule, most children 3 yo will be competent enough in language to be managed through language processes. By 4 yo all children without problems of psychological development should be competent in the domain of language.
Review domains of management techniques:
1)      Physical
a.       Papoose board, pedi-wrap, sheets, cloth wraps, Mouth Props, hands
b.      Possible long-term emotional consequences
2)      Pharmacologic
a.       Nitrous oxide, medications (PO, IM, IV…etc), General anesthesia, local anesthetics
b.      Potential dangers regarding respiratory depression, loss of gag reflex, eliminating wakefulness
3)      Aversive
a.       Voice control, time out, hand-over-the-mouth
b.      Noxious to encounter and sometimes even impossible for parents to observe
4)      Reward-oriented
a.       Promise of special gift by dentist or treat by parent
b.      Dangerous as child may interpret upcoming appointment as a threat due to the apparent anxiety from the parents because they are offering a treat or a gift
5)      Linguistic techniques
a.       Technique of choice for the cooperative preschool child
b.      Speech acts allow people to take effective actions together: requests and promises
                                                               i.      Request by the dentist and promises (response) by the child to the request
c.       In order to be effective, not only be able to frame an effective request, but to be able to “reframe” a request if denied by child
                                                               i.      Note that voice control (or sudden change in tone and/or facial expression) may be a reframe and not aversive…same applies to hand-over-the-mouth
d.      Desensitization also belongs in this technique
Origins of Misbehavior for “seemingly” normal child:
-          To develop behavior management strategy, the clinician needs to predict patient’s behavior based on Possible Fear in the Dental experience (10 fears in total)
·         Fear of dentistry and real fears
1)      Previous bad experience
2)      Fears acquired from sibling and peers
3)      Fear of the needle
·         Theorized fear
4)      Freudian (theoretical only)
·         Potential of acquiring fear from the clinician
5)      Child perception of the emotional state of the dentist or dental assistants
·         Protective fears of young children (have biogenetic origins: not learned but acquired as part of growing up) – should be minimal at 3yo, and be non-existent at 4yo
6)      Fear of the unknown
7)      Fear of pain
8)      Fear of bodily harm
9)      Fear of strangers
10)   Fear of separation
-          Avoidance behaviors:
o   Fear is useful as a means of helping to adopt an effective action to meet life’s challenges or tasks
o   Child may want to avoid dental appointment by imagining worst outcome possible and using that to either 1) embarrass the parent or 2) get the parent to play rescuer and patient the victim
o   Learned helplessness – child convinces him/herself that they cannot cope with new or unusual situations
o   Sometimes develops as an avoidance behavior to either get what they want or get out of what they don’t want at home
-          Illnesses and other traumas of life in a child can result in parents stopping reward or punishment in a consistent manner
o   Children need limits, rules, and solid feedback regardless of what’s going on in life
o   This category of parental pity includes kids experiencing divorcing parents, moving away to a new place, new siblings, loss of loved one (including pets)
-          Poverty – issues include economic, access to care, communication, preventive practices, social obstacles, cultural diversity
o   Children may have compromised ability to work with adults, especially those who are authoritative and seeking compliance
o   Children may have problems with learning and communicating
-          Prefigurative Child – not grounded in any sort of cultural traditions about expectations from children and how best to raise them
o   There is no commitment framework, so patient has no rehearsal in making promises in response to requests from the dentist
-          Children pursuing misdirected goal of childhood
o   Unusually attention-getting in relation to parents, as a means for social control of their adult parent
o   Can direct attitude to dentist also as an authoritative figure to manipulate
§  NOTE will need to formulate new management strategy once realize child’s motivation (i.e. tell-show-do will be useless, more voice control may be needed)
-          Abused and Neglected children (3 different categories)
1)      Physical
2)      Sexual
3)      Emotional abuse
o   An abused or neglected child may be emotionally compromised and have difficulty dealing with the rigors of a dental appointment
o   Often abuse and neglect can be difficult to detect, and analysis of patient to predict behavior may be difficult
Parental Dimension of Contemporary Pediatric Dentistry
-          Parent’s anxiety can influence the mood and cooperation of the child during treatment
-          Prefigurative paradigms of child rearing today
-          Increased litigation
-          Increased parental anxiety regarding welfare of children under care of healthcare provider
Need for Risk Management – more than just informed consent, but incorporates the behaviors of the dentist, staff, and office in general in addressing the anxieties a parent may have.
-          Importance in listening to parents allowing them to express their concerns
Rules of the Game
-          Prejean notes that “games” are being played by people in all aspects of human community
-          5 basic elements which both sides agree to:
1)      Point of the game (ex: child will need pulp and ssc)
2)      Existential rules (ex: tx will be this day, with local, DD, pulp as needed and crown)
3)      Rules of action (ex: assistant will get child, parent may/may not come back, sit quietly)
4)      Rules of strategy (ex: how best to prepare child, same bed time, no favors/presents)
5)      Rules to settle disputes (ex: if tx not started, can stop tx, but once started cannot stop tx, becomes an issue of dentist ethical responsibility)
Dentist as Ontological Coach
-          Fears of preschoolers almost always linguistic fears and not biological ones
-          Management preference is linguistic domain (which includes voice control and hand-over-the-mouth in a linguistic modality rather than aversive one)
-          Effective dentist can help guide the preschool patient through mental processes to cope with such fears, diminish such fears, and even eradicate them
“It is submitted that the dentist who actively engages patients in instructive coaching behavior, uses information to desensitize a perhaps suspicious patient, gives strong encouragement to a child who is looking for such, and reminds a wary child that the dental appointment made by the parent is all about that parent loving the child will find the world of behavior management of the preschool child refreshing and a tremendously rewarding professional experience.” P.786
1- Always keep in mind addressing the big picture of the patient
Assessment of Article:  Level of Evidence/Comments: