he Etiology and Prevalence of Ectopic Eruption of the Maxillary First Permanent Molar

Resident’s Name: Laura Randazzo Sabnani Date:3/27/2009

Article title:The Etiology and Prevalence of Ectopic Eruption of the Maxillary First Permanent Molar

Author(s): Pulver, Franklin

Journal: J. Dent for Children

Volume (number):

Month, Year:  March 1968

Major topic / Main purpose:  To determine the factors that influence ectopic eruption of the maxillary first permanent molar and to study the prevelance of ectopically erupting maxillary permanent first molars.  

Methods and Materials:  Children from the University of Michigan growth study, the department of pedodontics and orthodontics were used in the study.  Size of teeth, length of maxilla, calcification of teeth, eruption angle of the maxillary first permanent molar, time of eruption into occlusion, prevalence of the ectopic eruption, relative distribution of the ectopic eruption according to sex, quadrant, type, extend of resorption of second primary molar, and type of resulting occlusion, and related anomalies were studied.  

Result/Summary:  Out of 831 children 26 of them had 35 ectopic eruptions (3.1%).  There was no specific etiologic factor found to be common among all children.   It was found that there was larger than normal mean sizes of all maxillary primary and permanent teeth, larger affected first permanent molars and second primary molars, smaller maxillae, a more posterior position of the maxillae in relation to the cranial base, an abnormal angulation of eruption of the maxillary permanent first molar and a delayed calcification of some of the affected first permanent molars.  No sex difference or preference of sides was determined.  The severity of the ectopic eruption dictated the resulting occlusion and extend of resorption of the second primary molar.

Assessment of article:  Ok article.  Some interesting points to give to parents if they ask why their child has ectopic eruption.  

Ankylosis or primary molars: a future periodontal threat to the first permanent molar?

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Derek Banks Date: March 27, 2009
Article title: Ankylosis or primary molars: a future periodontal threat to the first permanent molar?
Author(s): J Kurol
Journal: Euro J Orthodontics
Volume (number): 13(5)
Month, Year: October 1991
Major topic: Eruption and Exfoliation
Minor topic(s): Ankylosis
Type of Article: part-retrospective study
Main Purpose: To determine if treatment modality (extract vs. let exfoliate) of infraoccluded primary second molars affects periodontal health of the first permanent molars
Overview of method of research: 68 subjects with history of ankylosed primary second molars. 57 had a follow-up (about 8 years later) clinical and radiographic exam. 11 had only a radiographic exam. Probing depths and bone levels were checked.
Findings: No significant periodontal defects were found in either group. In the extraction group 2 out of the 32 teeth had some bone loss, but normal periodontal probing depths. In the exfoliation group no appreciable bone loss or periodontal pockets were noted.
Key points/Summary : Do we really need to take out ankylosed primary second molars? From a strictly periodontal standpoint, not necessarily.
Assessment of article: Good article.

Relationship of Submerged Deciduous Molars to Root Resorption and Development of Permanent Successors

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Chad Abby Date: 2/20/2009
Article title: Relationship of Submerged Deciduous Molars to Root Resorption and Development of Permanent Successors
Author(s): S. Steigman, E. Koyoumdjisky-Kaye, and Y. Matrai
Journal: Journal of Dental Research
Volume (number): Vol 53, No. 1
Month, Year: January – February 1974
Major topic: Root resorption
Minor topic(s): relationship of submerged deciduous molars to root resorption and development of permanent successors
Type of Article: Clinical Study
Main Purpose: To determine whether submerged deciduous molars are a source of disturbance of the normal development of the permanent dentition and whether extraction is advocated.
Overview of method of research: Two-hundred seventy children (115 aged 4-6 years and 155 aged 7-10 years) with submerged, cariesfree deciduous molars participated in the study. A comparable sample of 270 children with normal, cariesfree deciduous molars served as a control. All deciduous molars with marginal ridges below those of the adjacent teeth were considered “submerged.” Root resorption was divided into six stages: no resorption, apex only, a third of the root, half of the root, two thirds of the root, and complete resorption of the root. In children with unilateral submerged molars, healthy contralateral teeth were used as controls.
Findings: No differences were found in the rate of root resorption between submerged and normal deciduous molars. The process of submerging in the deciduous molars did not delay the development of their permanent successors. Submerged deciduous molars should not be extracted unnecessarily.
Key points/Summary : It can be assumed that submerged teeth usually have no causative influence on the rate of development of their successors, and that the process of submerging should not be held responsible for retarded resorption of deciduous roots. Submerged teeth often exfoliate spontaneously in the normal age range. It was thought that submerged teeth should be extracted because they prevent the eruption of the succeeding permanent teeth. However, on the basis of this article a more conservative approach is suggested. Instead teeth need to be observed closely clinically and radiographically and only when it becomes obvious that resorption is not proceeding normally or that adverse occlusal changes are taking place, should extraction be considered.
Assessment of article: Good article, somewhat dated

Williams Syndrome

Literature Review Williams Syndrome Laura Randazzo Sabnani

Seen in 1/7500 births, present at birth, occurs in all ethnicities and effects males and females equally.
- Small upturned nose, long philtrum, wide mouth, full lips, small chin, puffiness around the eyes. Blue and green eyed children have a starburst ( a white lacy pattern on the iris)
- Most have heart or blood vessel problems such as narrowing of the aorta or pulmonary arteries, which can range from trival or severe, and cause an increased risk for high blood pressure.
- Young children can have elevated levels of blood calcium causing extreme irritability or colic-like symptoms
- Most children have low-birth weight and slow weight gain
- Feeding problems due to low muscle tone, severe gag reflex, poor suck/swallow, tactile defensiveness etc. May resolve as the children get older.
- Slightly small, widely spaced teeth are common. They also may have a variety of abnormalities of occlusion, tooth shape or appearance.
- Increased incidence of problems with kidney structure and/or function
- Inguinal (groin) and umbilical hernias are more common
- More sensitive hearing than other children; Certain frequencies or noise levels can be painful an/or startling, often this improves with age. (patient may be sensitive to the sound of the high speed) Young children often have low muscle tone and joint laxity. Joint stiffness may develop as children get older
- These children tend to have an excessively social personality. They are typically unafraid of strangers, extremely polite and show a greater interest in contact with adults than with their peers.
- Some degree of intellectual handicap. Young children with often experience developmental delays; milestones such as walking, talking and toilet training are often achieved somewhat later than is considered normal. Strengths and weaknesses are often seen in older children and adults. There are some intellectual areas (such as speech, long term memory, and social skills) in which performance is quite strong, while other intellectual areas (such as fine motor and spatial relations) are significantly deficient.
- Anesthesia concerns are the patient's cardiovascular system, kidney function, airway anatomy, metabolic status, joint mobility and level of cognitive functioning. “a cardiologic evaluation within the 12 months preceding surgery is desirable and records from the cardiologist should be requested for the anesthesiologists review. Copies of EKG'S, echocardiograms, chest x-rays (if available) and cardiac catheterizations (if appropriate) should be provided. The airway problems in WS concern the potential difficulty in placing an endotracheal tube for general anesthesia in the WS individual with an underdeveloped lower jaw. Dental problems, including brittle or loose teeth can compound this difficulty. These features are best noted when the anesthesiologist performs a brief, specific physical exam during the preoperative visit.”
www.williams-syndrome.org

Crouzon Syndrome

Significant craniofacial and/or oral features:
Lobed tongue
Hamartomas or lipomas of tongue
Cleft of hard or soft palate
Accessory gingival frenulae
Hypodontia
Ocular hypertelorism or telecanthus
Median cleft or pseudocleft upper lip
micrognathia

Etiology:
X-linked dominant genetic disorder and is mostly in females

Prevelene:
Estimates range from 1/50,000 to 1/250,000


Age of Diagnosis:
At birth in infants based on characteristic oral, facial, and digital anomalies, OR after polycystic kidney disease is identified in childhood

Factors that influence dental care or require dental intervention:
Treatment of cleft lip/palate, tongue nodules, accessory frenulae, removal of accessory teeth, and orthodontics for malocclusion
Speech therapy may be necessary


Associated systemic conditions:
Digital abnormalities
Brain abnormalities – intracerebral cysts, corpus callosum agenesis, cerebellar agenesis
Kidney – polycystic kidney disease
Mental retardation – usually mild
Skin and hair disorders such as alopecia

The teenagers reality

Resident’s Name: Brian Schmid Date: 9/19/08
Article title: The teenagers reality
Author(s): David Elkind PhD
Journal: Pediatric Dentistry
Volume (number): Vol. 9 #4
Month, Year: December 1987
Major topic: Theory of the “imaginary audience”, the ‘personal fable’ and how this affects a teenagers reality and actions
Minor topic(s: Applying these theories to increase compliance and put teenagers more at ease
Type of Article: Professional opinion
Main Purpose To encourage practitioners to assume the outlook of a teenager in order to better understand the motivation for their actions and inactions

Overview of method of research: Anecdotal

Findings: Becoming a teenager is now being accepted as the “second age of reason” in growing to adulthood, attaining the ability to form conceptual ideas about space and time as well as assuming the outlook of others. Since a teenagers experience is so vivid and engrossing to them, they assume that everyone, their own personal “imaginary audience”, is just as caught up in their self-obsession as they are. This construct has both positive and negative consequences; the audience can be a conscience keeping them from performing ill deeds that no one else may see. The audience also serves as a motivator for personal success. However, the need for acceptance by the imaginary audience can make young teenagers more susceptible to peer pressure, leading them to make rash and often injurious decisions. Teenagers also begin to develop the ‘personal fable’, which convinces the individual that bad things may happen to other people but not them; this delusion worsens their resistance to peer pressure. This personal fable also helps us deal with daily life without constantly worrying about our plane crashing or being struck by a wicked huge meteor. The fable also convinces the teenager that their experience is unique and could not possibly be understood by anyone else, least of all their parents who couldn’t be more unlike them. One of the most important inferences taken from these theories is that it is not lack of education which leads to bad decision making by teenagers, but rather we must wonder why teenagers disregard the consequences.

Key points/Summary : By applying the theories of the imaginary audience and the personal fable, we as health care professionals can at least attempt to assume the outlook of a teenager and better understand their motivations and actions. It does not help to fully accept or deny their suppositions but to put them to the test and let the teenager set the limits of their own audience.

Assessment of article: A clever theory attempting to border the mind of a risk-taking, self-obsessed teenager. Thinking in this way could help us increase compliance, for example wearing retainers or ortho rubber bands.

Rare Dental Abnormalities Seen in Occulo-Facio-Cardio-Dental (OFCD) Syndrome: Three Cases and Review of Nine Patients

Resident’s Name: Anna Haritos Date: October 3, 2008
Article title: Rare Dental Abnormalities Seen in Occulo-Facio-Cardio-Dental (OFCD) Syndrome: Three Cases and Review of Nine Patients
Author(s): Schulze et al.
Journal: American Journal of Medical Genetics
Volume (number): 82: 429-435
Month, Year: 1999
Major topic: characteristics of oculo-facio-cardio-dental syndrome
Minor topic(s): dental characteristics of OFCD syndrome
Type of Article: case report
Main Purpose: to highlight characteristics of this rare syndrome
Overview of method of research: presentation of three new cases of OFCD as well as review of 9 previous patient cases
Findings: OFCD syndrome has been confirmed only in female patients. X-linked dominant inheritance is most likely. All three cases discussed in this article presented with congenital cataracts and microphthalmia or microcornea. Two of the patients suffered from Atrial septal defect. All of the three patients had clefting of the hard and soft palate. Of the 9 reviewed patients and 3 new cases presented, 50% of the 12 patients were affected with clefting. The most important criteria leading to diagnosis of OFCD syndrom are dental abnormalities, specifically extreme elongation of the canine roots. All patients have radiculomegaly of the canines. Radiculomegaly also present in permanent incisors and premolars in some instances as well. Delayed eruption of deciduous and permanent teeth is also a distinctive characteristic of OFCD syndrome and is present in most patients.
Key points/Summary:
O – ocular anomalies: congenital cataract, secondary glaucoma and microphthalmia
F – facial appearance; narrow face, high nasal bridge, broadening of the nasal tip with separated cartilages, cleft palate or submucosous cleft palate
C – cardiac anomalies; atrial septal defect, ventricular septal defect
D – dental; radiculomegaly of canines, oligodontia, delayed dentition, retained deciduous teeth, hypodontia
Syndactyly of toes 2-3 and partial hearing loss also described;
intelligence can range from normal to retarded
Assessment of article: very clear; highlights the central role of dental anomalies in this rare syndrome

Pretreatment Modeling: A Technique for Reducing Children’s Fear in the Dental Operatory

Joanne Lewis
Date: 9-12-08

Article title: Pretreatment Modeling: A Technique for Reducing Children’s Fear in the Dental Operatory
Author(s): Paul E. Greenbaum, Ph.D.; Barbara G. Melamed, Ph.D.
Journal: Dental Clinics of North America
Volume (number): 32
Month, Year: October 1988
Major topics: The use of modeling as a pretreatment preparation to reduce children’s fear and misbehavior during dental treatment.
Minor topics: N/A
Type of Article: Review of research
Main Purpose: Present and summarize the research regarding modeling as a behavior guidance technique; includes advice on implementation of modeling in a dental practice.
Overview of method of research: Review of research
Findings: This article seeks to answer several questions:
How well does modeling work?
Children who were exposed to modeling (watched an older sibling receive dental treatment) had more positive behavior during treatment, for both a cleaning and exam and for a restorative appointment. Yes, modeling can reduce patient fear associated with treatment.
Does the child’s age or gender affect the effectiveness of modeling?
According to the research, modeling has been shown to reduce fear behavior among male and female children and across a wide age range – 3 to 13 years of age.
Does the child’s fear level affect the effectiveness of modeling?
The research shows that modeling reduces patient fear in both high and mild to moderate fear level children.
Is modeling more effective on children with previous dental experience or on children with no previous dental experience?
Modeling preparation by itself is more effective on children with no previous dental experience. However, modeling in combination with other techniques (coping instructions, imagery, etc.) may be effective in children with previous dental experience.
What behavior should be modeled?
2 components – 1.) the child must vicariously receive rewards, either the model receives reinforcement or the model does not receive any adverse consequences and 2.) the child must be presented with information about the upcoming dental treatment and how to handle it.
Should the model be highly similar to the patient, or of high prestige?
Both similar and high status models can be effective.
Is a symbolic model as effective as a live model? – YES!
Should mothers (parents) be allowed in the operatory during dental treatment?
Mothers often act as a natural model for their children’s behavior. The parent is an important model in children’s ability to cope with stress.
Key points/Summary :
Modeling is an effective behavior management technique to reduce fears and decrease disruption, especially in patients with no prior dental exposure. Many practitioners do not currently use modeling; in the past, it was a difficult technique to implement. Now with videos and DVD’s, modeling could gain more widespread use, especially if a set of standardized modeling tapes was developed.
Assessment of article:
A good reminder of a behavior guidance technique that is familiar and intuitive – really, just an expansion on tell-show-do. Makes a good case to increase the use of modeling in the pediatric dental office.

FETAL ALCOHOL SYNDROME

Resident’s Name: Joanne Lewis Date: October 10, 2008

FETAL ALCOHOL SYNDROME
What is affected in the syndrome?
• Growth deficiency
• Facial features – three diagnostically significant features:
o Smooth philtrum
o Thin upper lip
o Small palpebral fissures – decreased eye width
(note: these facial features strongly correlate with brain damage)
• Central nervous system damage
o Structural abnormalities of the brain – microcephaly
o Neurological impairments – seizure disorders, poor hand-eye coordination, poor fine motor skills
o Functional impairments – learning disabilities, poor impulse control, poor judgment, attention and hyperactivity problems (ADHD), poor social skills, mental retardation
• Heart murmur by 1 year of age
• Joint anomolies, small distal phalanges
• Renal problems – horseshoe, aplastic, or dysplastic kidney
• Decreased visual acuity
• Secondary disabilities
o Mental health problems
o Disrupted school experience
o Trouble with the law
o Confinement
o Inappropriate sexual behavior
o Alcohol and drug problems
How? Fetal alcohol exposure is the leading known cause of mental retardation in the Western world, with a prevalence rate of 0.2 to 2.0 cases per 1,000 live births. There is no clear consensus as to what level of exposure is toxic.
How is the diagnosis made? Criteria for a FAS diagnosis are:
• Growth deficiency – prenatal or postnatal height or weight at or below the 10th percentile
• All three FAS facial features present
• Central nervous system damage
• Prenatal alcohol exposure

Why are we interested? The first step in the management of a dental patient with FAS is recognition of the condition. This is best accomplished via the medical history and open discussion with the patient or family members. Once a patient with FAS is identified, the dental practitioner must learn as much as possible about the history of the patient, including type and extent of systemic manifestations and any current medications. Dental treatment will have to take into account:
• Consultation with physician to determine if the patient needs antibiotics prior to dental treatment due to heart murmur
• Behavior problems
• Orofacial manifestations including cleft lip/palate, dental malocclusions, poor muscular tone around the mouth (excessive drooling), deficient maxilla or mandible
• The ability of the patient to metabolize medications


Items of interest: Many patients with FAS have sensory integration dysfunction, a neurological condition that causes sights, sounds, and physical sensations to be over or under exaggerated. Think about the dental office!

Ethical issues in managing the noncompliant child

Resident’s Name: Chad Abby Date: 9/19/2008
Article title: Ethical issues in managing the noncompliant child
Author(s): Ann L. Griffen, Lawrence J. Schneiderman
Journal: Pediatric Dentistry
Volume (number): Volume 14, Number 3
Month, Year: May/June 1992
Major topic: Behavior Management
Minor topic(s): ethical issues in behavior management techniques
Type of Article: Case review
Main Purpose: How best to handle patients who refuse dental treatment.
Overview of method of research: To help answer the question for behavior management interventions five areas of consideration were analyzed – the indications for treatment, patient autonomy, the benefits of dental treatment versus the burdens of a management intervention, the desires of parents, and external factors such as allocation of resources. Cases were presented and appropriate action discussed.
Findings: Children are not granted the legal autonomy, or right to refuse or consent to treatment (under 18) because they may not be competent to act in their own best interests. However, we need to seek the child’s assent to treatment in combination with permission of the parent or guardian. Assent asks that pediatricians involve children to participate in making decisions about their health and health care to the extent that they are able. Studies have shown that children under the age of seven have very little capacity to appreciate the consequences of treatment options. The estimation of capacity and determination of level of involvement in decision making lie within the judgment of the health professional. When deciding to use a management technique, the associated risks must be assessed. 1 in 10,000 of all anesthetized patients die of causes primarily attributal to anesthesia, although the risk to healthy patients is considerably lower. This risk is less than that of one year of normal automobile travel during which death rates are 2 in 10,000 persons. If parents refuse all reasonable treatment options offered, the dentist is obligated to attempt to educate to overcome ungrounded fears or misapprehensions. In cases of failure to obtain needed dental treatment, the dentist may be obligated to report the neglect to the appropriate agency to protect the child. At times economic factors may limit the use of general anesthesia for many patients, often those who need it most. The dentist’s obligation is to the patient, and considerations of public expense and attempts to ration or allocate scarce or limited resources ideally should be dealt with at a policy-making level and should not enter into individual treatment decisions.
Key points/Summary: Patient autonomy, or the right of self-determination, including the right to refuse treatment, is a fundamental right of all competent patients. Often as pediatric dentists we need to make this choice for the child because they may be incapable of appreciating the consequences of their choices. The following areas should be considered ethical decision making when a patient refuses treatment: Indications-carefully reconsider the urgency of the dental needs and determine if treatment can be delayed or avoided with no lasting ill effects; Assent- estimate the capacity of the child to participate in decision making, and involve the child to the extent of that capacity; Benefits versus burdens- determine what management techniques are likely to make treatment possible in a given situation; Permission- obtain parents’ permission after presenting a description of the recommended techniques, alternatives, and an assessment of the risks associated with refusing treatment; External factors- pediatric dentists have a responsibility to attempt to shape policy to make care more available on the basis of need as part of an overall system of justly distributed health care.
Assessment of article: Great article to review once in a while

Freeman-Sheldon Syndrome

Freeman-Sheldon Syndrome, also termed distal arthrogryposis type 2A (DA2A), craniocarpotarsal dysplasia (or dystrophy), or whistling-face syndrome, was originally described by Freeman and Sheldon in 1938.


Signs and symptoms
Features include:
• talipes equinovares - club foot



• camptodactyly - permanent flexure of one or more phylanges





• scoliosis - “S” or “C” shaped spinal curvature

• microstomia, often only a few millimeters in diameter at birth resulting from contractures of facial muscles; “whistling-face syndrome”



• high-arched palate
• attenuated movement of the muscles of facial expression

Cause
• FSS is caused by genetic changes
• Inheritance may be either autosomal dominant or autosomal recessive

Epidemiology

• As of 1990, 65 FSS patients had been reported in the literature, with no sex or ethnic preference notable.
• Some individuals present with minimal malformation; rarely patients have died during infancy as a result of severe CNS involvement or respiratory complications.
• Life expectancy is normal

Management
• Patients must have early consultation with craniofacial and orthopedic surgeons when craniofacial, clubfoot, or hand correction is indicated to improve function or aesthetics.
• Early interventions hold the possibility to minimise developmental delays and negate the necessity of relearning basic functions.
• Due to the abnormal muscle physiology in Freeman-Sheldon syndrome, therapeutic measures may have unfavourable outcomes

• Difficult endotracheal intubations and vein access complicate operative decisions in many patients

• Malignant hyperthermia may affect individuals with FSS, as well
• Focus is on limiting exposure to infectious diseases because the musculoskeletal abnormalities make recovery from routine infections much more difficult in FSS patients.
• Pneumonitis and bronchitis often follow seemingly mild upper respiratory tract infections.
• Respiratory challenges and complications faced by a patient with FSS can be numerous but the syndrome’s primary involvement is limited to the musculoskeletal systems, and satisfactory quality and length of life can be expected with proper care.

Psychiatric Considerations
• Mitigation of lasting psychological problems, including depression secondary to chronic illness and posttraumatic stress disorder (PTSD), can occur
• Patients with FSS should have pre-emptive and ongoing mixed cognitive therapy
Research
• FSS is an extremely rare condition, therefore systematic research is considered a low priority by major funders
• The priority for limited research funds is to determine the role and nature of malignant hyperthermia in FSS.
• Further research is wanted to determine epidemiology of psychopathology in FSS and refine therapy protocols

de Lange Syndrome

Incidence:
Approximately 1:10,000 live births and believed to be caused by a gene mutation.

Common charachteristics: low birth weight (under 5lbs), slow growth, small stature, small head size, thin eyebrows which often meet in the midline, long eyelashes, short upturned nose and thin downturned lips, excessive body hair, small hands and feet, partial joining of the second and third toes, incurved fifth fingers, missing limbs or portion of limbs, usually fingers, hands or forearms.

Common medical problems include: GERD, seizures, heart defects, cleft palate, bowel abnormalities, feeding difficulties, and developmental delay, mental retardation ranging from mild to profound. (most are mild to moderate)

Absent or minimal speech has been noted in most children but it is clear that all do communicate. The ability to speak for most individuals is much more difficult than the ability to comprehend language.

Mild to moderate hearing loss or even severe hearing loss is in almost all children with this syndrome.

Strabismus (misalignment of the eye), nystagmus (shaky eyes), nearsightedness, ptosis (drooping of one or both eyelids) are commonly seen in patients with de Lange syndrome. Also, blepharitis is seen in 50% of patients and manifests as recurrent red eyes, crusting on the eyelashes, itchy eyes, tearing, or eye discharge, due to suboptimal flow in the eyelid.

Dental:
These patients tend to have small jaws, poor OH, crowded teeth, small teeth, perio dz, and erosion of teeth due to GERD. Cleft palate is common and should be repaired as soon as possible to help improve speech, reduce ear infections leading to hearing loss, and improve the ability to eat.

Cardiac:
20-30% have congenital heart disease ranging from mild to severe defects. All patients who are diagnosed with this syndrome should be evaluated by a cardiologist.

Behavior:
Patients may be described as being hypersensitive; having strong reactions to ordinary stimiuli that last long after the stimulus is removed. Patients may also be described as being disrhythmic; irregular behavior in eating, sleeping and emotional response.

The Cornelia de Lange Syndrome website www.cdlsusa.com is a great resource with a ton of information if you would like more on this syndrome.

Achondroplasia

Name: Craig Elice Date: October 3, 2008

Achondroplasia is an autosomal dominant that is a common cause of inherited dwarfism with disproportionate short stature with a normal sized torso and distal appendages. Its prevalence is 1 in 25000 births. Molecular analysis reveals a deficiciency in the fibroblast growth factor receptor. In 99% of the cases it is due to a mutation in the FGFR3 gene which indicates that there is a low risk of having another child with achondroplasia. There is an association with increased paternal age.

Diagnosis is made with a prenatal ultrasound. Infants generally have low muscle tone and slow motor development like sitting up and walking. Because of the narrow middle ear canals, these patients are susceptible to ear infections. A skeletal survey shows a large skull, with a small skull base, short ribs and a narrowing of the interpediculate distance between caudal vertebrate. A notch like sacroiliac groove is also indicative of achondroplasia. These patients have abnormal bone growth resulting in short stature and disproportionately short arms and legs. Average height is approximately 131 cm for males and 124 cm for females. They also have frontal bossing and midfacial hypoplasia.

These patients are often obese at a young age and develop sleep apnea. Adults frequently have symptomatic spinal stenosis of the lumbar vertebrae at L1-4 requiring pain medication and sometimes surgical intervention.

In terms of dental manifestations, the facial structures are listed above with midfacial hypoplasia. As a result, the patients frequently have severe crowding requiring orthodontic intervention.

Dentists’ voice control: effects on children’s disruptive and affective behavior

Name: Craig Elice Date: September 12, 2008
Article title: Dentists’ voice control: effects on children’s disruptive and affective behavior.
Author(s): Greenbaum, PE, Turner C., Cook EW., and Melamed BG.
Journal: Health Psychology
Volume (number): 9(5) 546-558
Month, Year: 1990
Major topic: Behavior Management—Voice control
Type of Article: Prospective study
Main Purpose: The study evaluated (1) whether loudness is a requirement for the use of voice control or is a normal tone equally effective, (2) if voice control reduces children’s disruptive behavior, and (3) the after treatment affect on children. Does long-term dental fear increase when punishment (voice control) is used?
Overview of method of research: Forty patients (23 male and 17 female) ages from 3.5 to 7 years scheduled for cavity restoration who were considered potential behavior problems and were treated by 3 pediatric dentists who use voice control in daily practice. Treatment was randomized into two groups, loud VC, and normal voice VC, and lastly if behavior was good, a non-experimental control. A pretreatment Children’s Fear Survey Schedule Dental subscale and a Self Assessment Mannequin test were given. Videotapes of the procedure were scored using a Behavior Profile Rating Scale to measure fear and disruptive behavior. At the end of treatment, dentists rated children’s fear and cooperation. After leaving the operatory, children again rated feelings using the SAM test.
Findings: The groups were evaluated statistically for age, gender, dentist voice modulation, pre treatment fear and pretreatment feelings. Their distributions were not significantly different. Post intervention behavior showed that the loud voice group was less disruptive then normal voice VC within two seconds after receiving loud VC, and lasting for the measured duration of 2 minutes. The SAM score measuring affect showed significantly greater pleasure and lower arousal (greater calmness) for the loud VC group. The dominance affect had no significance between groups.
Key points/Summary: VC was a highly effective punishment technique to reduce childrens disruptive behavior for ages 3.5 to 7 years of age. Although one of the components of long term dental fear is a negative experience, this form of negative reinforcement did not elicit any long-term negative sequelae as measured by the SAM scores
Assessment of article: This study was able to integrate various psychological tests to determine the effectiveness of a commonly used technique in pediatric dentistry. It further validates the use of voice control in today’s pediatric dental practice .

Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth.

Resident’s Name: Joanne Lewis Date: 08/22/2008
Article title: Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Author(s): Flores et al Journal: Dental Traumatology Volume (number): 23 Month, Year: 2007 Major topic: Management of fractures and luxation injuries to the permanent teeth. Minor topic(s): N/A Type of Article: Guidelines Main Purpose: To present guidelines developed by the International Association of Dental Traumatology. Overview of method of research: The guidelines were developed as a consensus statement after a review of the dental literature and group discussions. Findings: Guidelines are presented in a table format in the article. Key points/Summary: General recommendations for management include: - Clinical examination - Radiographic examination with several projections (PA, occlusal view, lateral view) - Sensibility testing - may yield false negative initially - Diet / hygiene instructions, including brushing with a soft brush and rinsing with chlorhexidine Assessment of article: The tables are a nice quick reference for managing fracture and luxation injuries of permanent teeth.

Rett syndrome

Resident’s Name: Chad Abby Date: 10/10/2008

Rett syndrome:
Rett syndrome (RTT) is a unique neurodevelopment disorder that is most often misdiagnosed as autism, cerebral palsy, or non-specific developmental delay. RTT is a genetic disorder of developmental arrest or failure of brain maturation. This disorder is found almost exclusively in females.

What is affected in the syndrome?
In RTT subsets of neurons and their connections (synapses) are disrupted during a very dynamic phase of brain development. This causes a slowing down or stagnation of motor skills, a loss of communication skills and purposeful use of hands and a slowing of normal rate of head growth (microcephaly). Gait disturbances are noticed and problems may include disorganized breathing patterns and seizures. As a child with RTT gets older motor problems may increase, while interaction and communication, especially with eye gaze, seizures, and irregular breathing may improve. Most individuals with RTT require maximum assistance with every aspect of daily living.

Why?
Rett syndrome is caused by a sporadic mutation in the MECP2 gene on the X chromosome. The MECP2 gene plays a role in turning off or regulating other genes. So a mutation would cause the turn off regulatory mechanism to fail allowing other genes to function abnormally.

When – in the child’s life is the diagnosis made?
The child with RTT is usually born healthy and shows an early period of apparently normal or near normal development until 6-18 months of life, when there is a slowing down or stagnation of skills. A period of regression then follows when she loses communication skills and purposeful use of her hands and slowing of the normal rate of head growth become apparent.

Factors that can influence dental care or cause the need for dental treatment?
Some medicines used to control epilepsy e.g. Phenytoin, can cause overgrowth of the gums. Plaque removal is even more important for patients who are at risk of this overgrowth; plaque can accumulate even more when gums are swollen. Be aware of the sugar content of medicines. Ask for sugar-free formulations for over-the-counter medicines. If sugared medicines must be used, try to avoid giving them last thing at night. Some drugs can cause a dry mouth, which can increase the risks of tooth decay. Tooth grinding is also a problem seen in Rett syndrome. Due to poor motor functions a provider will always be necessary to adequately clean the teeth of a child with Rett syndrome. It has been noted that Rett syndrome patients can have supernumerary teeth (extra teeth or fused teeth). These may make cleaning more difficult and they can also delay eruption of adjacent teeth. Regular visits to the dentist and good home care can prevent the need for invasive dental treatment.

Systemic or medical conditions associated with the syndrome that are critical concerns for dental work?
By age 5, your child should have an ECG performed. If normal, it should be repeated every other year. If abnormal, a cardiologist should be consulted. When treating a child with Rett syndrome a medical consult should always be performed with the cardiologist before treatment. Apraxia (dyspraxia), the inability (or reduced ability) to program the body to perform motor movements, is the most fundamental and severely handicapping aspect of RTT. It can interfere with every body movement, including eye gaze and speech, making it difficult for the girl with RTT to do what she wants to do. Rett syndrome is not a degenerative disorder, but rather is a neurodevelopmental disorder. Barring illness or complications, survival into adulthood is expected.



Information that has been recently learned?

Rett Syndrome was previously described as a neurodegenerative disorder, with very poor prognosis and little potential for learning. Scientific studies have now identified Rett Syndrome as a disorder of neurodevelopmental arrest, which begins shortly before or after birth at a critical time of brain and synapse formation.

Traumatic crown fractures in permanent incisors with immature roots: a follow-up study

Resident’s Name: Laura Randazzo Sabnani Date: August 22, 2008
Article title: Traumatic crown fractures in permanent incisors with immature roots: a follow-up study
Author(s): Cavalleri G, Zerman N
Journal: Endodontics and Dental Traumatology
Volume (number):
Month, Year: 1995
Major topic: Traumatic crown fractures in permanent incisors with immature roots
Minor topic(s:
Type of Article: Follow-up study
Main Purpose: To record the different types of trauma to permanent incisors and the prognosis
Overview of method of research : 55 patients and 84 injured incisors with incomplete root formation were included in the study. The teeth were followed over a 5 year period. The crown fractures were divided into categories 1. Fracture of enamel 2. Fracture of enamel and dentin 3. Fracture of enamel and dentin with pulp involvement. Any teeth with associated subluxation, luxation, root and/or crown-root fractures were excluded.
Findings: 8 year olds were most commonly injured. 3.6 to 1 boys/girls. 95% were maxillary central incisors. Most common injury was fracture of enamel dentin without pulpal involvement. 51% had a associated soft tissue lesion. 40% of injuries occurred in pts with overjets greater than 3mm.
Key points/Summary : All three teeth with fractured enamel had no pulp complications. Out of 67 teeth with uncomplicated fractures 4 teeth showed pulp necrosis and 1 showed pulp obliteration. Out of 14 teeth with complicated fractures 8 showed pulp necrosis. 34 (40.5%) restored teeth had to be retreated because of a new trauma.
Assessment of article: Good article although I found it somewhat confusing at times.

Traumatic crown fractures in permanent incisors with immature roots: a follow-up study

Resident’s Name: Laura Randazzo Sabnani Date: August 22, 2008
Article title: Traumatic crown fractures in permanent incisors with immature roots: a follow-up study
Author(s): Cavalleri G, Zerman N
Journal: Endodontics and Dental Traumatology
Volume (number):
Month, Year: 1995
Major topic: Traumatic crown fractures in permanent incisors with immature roots
Minor topic(s:
Type of Article: Follow-up study
Main Purpose: To record the different types of trauma to permanent incisors and the prognosis
Overview of method of research : 55 patients and 84 injured incisors with incomplete root formation were included in the study. The teeth were followed over a 5 year period. The crown fractures were divided into categories 1. Fracture of enamel 2. Fracture of enamel and dentin 3. Fracture of enamel and dentin with pulp involvement. Any teeth with associated subluxation, luxation, root and/or crown-root fractures were excluded.
Findings: 8 year olds were most commonly injured. 3.6 to 1 boys/girls. 95% were maxillary central incisors. Most common injury was fracture of enamel dentin without pulpal involvement. 51% had a associated soft tissue lesion. 40% of injuries occurred in pts with overjets greater than 3mm.
Key points/Summary : All three teeth with fractured enamel had no pulp complications. Out of 67 teeth with uncomplicated fractures 4 teeth showed pulp necrosis and 1 showed pulp obliteration. Out of 14 teeth with complicated fractures 8 showed pulp necrosis. 34 (40.5%) restored teeth had to be retreated because of a new trauma.
Assessment of article: Good article although I found it somewhat confusing at times.

TURNER’S SYNDROME

What is affected in the syndrome? Common symptoms of Turner’s syndrome include:
• Short stature
• Lymphedema of the hands and feet
• Broad chest (shield chest) and widely-spaced nipples
• Low hairline
• Low-set ears
• Reproductive sterility
• Rudimentary ovaries gonadal streak (underdeveloped gonadal structures)
• Amenorrhea
• Increased weight, obesity
• Shield shaped thorax of heart
• Shortened metacarpal IV (of hand)
• Small fingernails
• Characteristic facial features
• Webbing of the neck
• Coarctation of the aorta and other cardiovascular defects (bicuspid aortic valve)
• Poor breast development
• Horseshoe kidney
• Visual impairments
• Ear infections and hearing loss
• Micrognathia
• Cubitus valgus (turned-out elbows)
• Drooping eyelids and palmar crease
• Narrow maxilla
Why? Turner’s syndrome (XO syndrome) or Ullrich-Turner syndrome encompasses several conditions, of which monosomy X is the most common. It is a chromosomal disorder affecting females in which all or part of one of the X chromosomes is absent. Occurring in 1 out of every 2500 girls, the syndrome manifests itself in a number of ways. Approximately 98% of all fetuses with Turner’s syndrome result in miscarriage.
When in the child’s life is the diagnosis made? Turner’s syndrome may be diagnosed by amniocentesis during pregnancy. Sometimes, fetuses with Turner’s syndrome are identified by abnormal ultrasound, findings (i.e. heart defect, kidney abnormality, cystic hygroma, ascites). In the postnatal period, Turner’s syndrome can be diagnosed by karotyping.
Why are we interested? Patients with Turner’s syndrome often present with a narrow, high, arched maxilla and the mandible tends to be wide and micrognathic. There is a high incidence of anterior and posterior open bite and posterior crossbite. Other dental abnormalities include early eruption of the permanent teeth, thinner enamel, less dentin, and shorter roots with a greater potential for root resorption during orthodontic treatment.
What are other systemic/medical conditions associated with the syndrome that are critical concerns if patient needs dental care? Prophylactic antibiotics should be used in patients with Turner’s syndrome with known cardiac malformations.
Information that has been learned recently: It has recently been found that there is a broader spectrum of cardiovascular system abnormalities in TS than previously known. There is a generalized dilation of major vessels in women with TS; the distal extent of this dilated vasculopathy is unknown.
Items of interest: The majority of girls and women have normal intelligence; however, they show some other functional deficits – problem solving, visuospatial organization, social cognition, and motor deficits. Many girls treated with growth hormones can attain normal or near-normal stature, and many women with TS are now able to carry pregnancies to full term due to advances in fertility treatments.

The legal status of informed consent for behavior management techniques in pediatric dentistry

Resident’s Name: Joanne Lewis Date: September 19, 2008
Article title: The legal status of informed consent for behavior management techniques in pediatric dentistry
Author(s): Patricia P. Hagan, DDS, MS, et al
Journal: Pediatric Dentistry
Volume (number): Vol. 6 No. 4
Month, Year: December 1984
Major topic: the legal obligation of informed consent with regard to the use of certain behavior management techniques
Minor topic(s): the history and background of informed consent within the medical and legal professions
Type of Article: Educational
Main Purpose: to examine the legal status of informed consent as it applies to behavior management techniques in pediatric dentistry
Overview of method of research: Reviewed findings from court cases and research articles.
Findings: There is a national trend of expansion and defense of patient’s rights. The idea of informed consent gained attention with a case in California in 1957, and it is now widely accepted that consent is only valid if it is informed. Informed consent encompasses both express consent (consent for a specific procedure) and implied consent (consent that is inferred by the patient’s actions). Pediatric dentists may run into problems if they feel that parents gave implicit consent for behavior management when they gave express consent for dental treatment. Historically, most states have adhered to the “professional community” standard for a guideline as to what information the health professional was required to provide – that is, the doctor was required to disclose information which a reasonable practitioner would make under the same or similar circumstances. Recently, an alternative standard, the “reasonable patient” standard, has developed in American courts. Under this standard, a practitioner may be held liable if the patient or parent did not receive all the information that was material to their decision to accept or reject proposed treatment. Research shows that parents rank the use of HOME and restraint devices as unacceptable as sedation and general anesthesia. Therefore, dentists who use HOME or patient restraint should obtain express parental consent for their use, since these procedures would be considered significant to the average patient.
Key points/Summary: There is a national trend towards the “reasonable patient” standard, but it varies state by state. Any dentist will minimize legal problems by obtaining express consent for any procedure that the average patient might find objectionable. Failure to obtain express consent for any material medical fact constitutes a legal wrong to the patient, even if no physical injury occurs. The informed consent doctrine is designed to give patients and parents a more meaningful guarantee of personal choice in health care matters. Ultimately, the best defense for potential disputes is to prevent them from arising, so if you plan to use HOME or physical restraint, get an informed consent.
Assessment of article: A rather dull article, but a good reminder of how to stay out of trouble.

Dental caries – a transmissible and infectious disease revisited: a position paper

Resident’s Name: Joanne Lewis Date: October 17, 2008
Article title: Dental caries – a transmissible and infectious disease revisited: a position paper
Author(s): Page W. Caufield, DDS, PhD
Journal: Pediatric Dentistry
Volume (number): 19:8
Month, Year: 1997
Major topic: the natural history of dental caries
Minor topic(s): transmission of s. mutans from mother to infant
Type of Article: Position paper
Main Purpose: To discuss the natural history of dental caries, with an emphasis on the mutans streptococci as the primary cariogenic biota.
Overview of method of research: Review and summary of research done at the author’s laboratory over the last 20 years; review of other research relating to the topic
Findings: The mutans streptococci (MS – mainly s. mutans and s. sobrinus) are principal members of a cariogenic flora, and without them, caries would be minimal or nonexistent. However, merely counting the number of MS is not sufficient to predict risk. Three concepts: 1.) Window of infectivity. Most infants acquire MS between 19 and 33 months of age (median age of 26 months). The presence of the first and second primary molars was key events in the initial acquisition of MS because they introduce fissured surfaces. Virgin molars provide a surface were MS can colonize without having to compete with other microflora. The window closes after all 20 primary teeth erupt and become colonized by other microorganisms. 2.) Fidelity of transmission (source of MS to infant). Mothers are the primary source of oral microbes to their children. When studies were done comparing the strain of MS found in the mother to the strain of MS found in her child, some interesting things were found. The fidelity of transmission between mothers and their female infants was significantly better than the fidelity of transmission between mothers and their male infants. African-American mothers transmitted MS to their infants with greater fidelity than white mothers. There was not one instance of strains of MS common to father and child. Breast-fed infants acquire MS with greater fidelity than non-breastfed infants. and 3.) Clonality – some strain of MS are more virulent than others. Strains that contain a certain plasmid (5.6 kb plasmid) are more virulent. In one study, it was found that no two isolates of MS were the same unless their hosts were related.
Key points/Summary: In the future, pediatric dentists may be using diagnostic tools such as DNA-based tests to identify particular strains of cariogenic bacteria. That information could then be used for treatment planning from a preventive point of view.
Assessment of article: It’s motivating to think about caries as a transmissible infectious disease that could potentially be cured. In a dream world, it would be really interesting to genotype the SM cultures we are collecting in the ECC study.

Intrusion injuries of primary incisors. Part III: Effects on the permanent successors

Resident’s Name: Anna Haritos Date: August 8, 2008
Article title: Intrusion injuries of primary incisors. Part III: Effects on the permanent successors
Author(s): Diab, M et al.
Journal: Quintesscence International
Volume (number): 31: 377-384
Month, Year: 2001
Major topic: primary tooth trauma in relationship to permanent tooth
Minor topic(s): none
Type of Article: literature review
Main Purpose: to evaluate common etiology and progression of primary intrusion, particularly in relation to development of permanent successors
Overview of method of research: Review of the literature
Findings: 44% of intruded, discolored teeth demonstrated damage to their successors. Only 3 mm of hard tissue exists between the primary incisor and its successor; In younger patients, this barrier may be mostly/only fibrous connective tissue. Younger children are more susceptible to permanent tooth damage from primary incisor intrusion as the successor crown does not complete formation stage until age 3. The permanent tooth can also be traumatized during its mineralization stage. Intrusion of a primary incisor that results in the root heading palatally (crown labially) is a bad intrusion as is more likely to impinge on toothbud; an intrusion resulting in the root headed labially and the crown palatally has a much better prognosis for the toothbud. As long as you can achieve good follow-up, it is better to let the tooth re-erupt spontaneously rather than extract. In the permanent teeth, yellow-brown spots suggest introduction of blood products during enamel matrix formation. White spots indicate hypomineralization. Other changes in permanent teeth come from movement of the ameloblasts as they lay down enamel, resulting clinically in pits, grooves, and/or altered shape. If the trauma occurs at age 2, a crown dilaceration may appear in the permanent tooth. When the trauma occurs between the ages of 2-5, root malformations may be present in the permanent tooth.
Key points/Summary: intrusive displacement of primary incisors is associated with pulpal and periodontal structure damage and possible fracture of alveolar bone. The trauma to the pulp may result in discoloration of the tooth and/or pulpal necrosis and infection. If the periodontal ligament is severely injured, ankylosis of the primary tooth may occur. The latter can cause delayed or ectopic eruption of the permanent successor.
Assessment of article: Very good review of what can happen to permanent tooth following primary tooth intrusion

Familial Dysautonomia - Riley-Day Syndrome

Overview

• Disorder of the autonomic nervous system
• Affects the development / survival of sensory, sympathetic, and some parasympathetic neurons in the autonomic and sensory nervous system
• Symptoms:
1. insensitivity to pain, inability to produce tears, poor growth, and labile blood pressure (episodic hypertension and postural hypotension).
2. Frequent vomiting crises, pneumonia, problems with speech and movement, difficulty swallowing, inappropriate perception of heat, pain, and taste, as well as unstable blood pressure and gastrointestinal dysmotility.
• FD is one example of a group of disorders known as hereditary sensory and autonomic neuropathies (HASN)
• HSAN are characterized by widespread sensory dysfunction and variable autonomic dysfunction caused by incomplete development of sensory and autonomic neurons.
Incidence
Almost exclusively in Ashkenazi Jews
Inherited in an autosomal recessive fashion
Both parents must be carriers in order for a child to be affected.
Carrier frequency in Jewish individuals of Eastern European (Ashkenazi) ancestry is about 1/30
Carrier frequency in non-Jewish individuals is about 1/3000
If both parents are carriers, there is a one in four, or 25%, chance with each pregnancy for an affected
Genetic testing is recommended for families who may be carriers of familial dysautonomia.
There have been 590 cases in total
Currently there are 350 people living with this condition worldwide

Etiology
• Familial Dysautonomia, is the result of mutations in IKBKAP gene on chromosome 9
• Chromosome 9 encodes for the IKAP protein
• Three mutations in IKBKAP identified in individuals with FD
• The decreased amount of functional IKAP protein in cells causes Familial Dysautonomia.

Symptoms
Symptoms displayed by a infant / toddler:
1. The most distinctive clinical feature is absence of overflow tears with emotional crying after age 7 months. This symptom can manifest less dramatically as persistent bilateral eye irritation.
2. High prevalence of breech presentation
3. Weak or absent suck and poor tone
4. Poor suck and misdirected swallowing
5. Red blotching of skin
Symptoms in an older child:
1. Delayed speech and walking
2. Unsteady gait
3. Spinal curvature


4. Poor growth
5. Less perception in pain or temperature with nervous system
6. Erratic or unstable blood pressure
7. Red puffy hands
8. Dysautonomia crisis: constellation of symptoms response to physical and emotional stress; usually accompanied by vomiting, increased heart rate, increase in blood pressure, sweating, drooling, blotching of the skin and a negative change in personality.
Clinical Diagnosis Criteria

• No fungiform papillae on the tongue
• Decreased deep tendon reflexes
• Lack of an axon flare following intradermal histamine
• No overflow tears with emotional crying
• Parents of Ashkenazi Jewish Background

Treatment / Treatment of Symptoms
1. Artificial tears: using eye drop containing artificial tear solutions (methylcellulose)
2. Feeding: Maintenance of adequate nutrition, avoidance of aspiration; thickened formula and different shaped nipples are used for baby.
3. Daily chest physiotherapy (nebulization, bronchodilators, and postural drainage): for Chronic lung disease from recurrent aspiration pneumonia
4. Special drug management of autonomic manifestations such as vomiting: intravenous or rectal diazepam (0.2 mg/kg q3h) and rectal chloral hydrate (30 mg/kg q6h)
5. Protecting the child from injury (coping with decreased taste, temperature and pain perception)
6. Combating orthostatic hypotension: hydration, leg exercise, frequent small meals, a high-salt diet, and drugs such as fludrocortisone.
7. Treatment of orthopedic problems (tibial torsion and spinal curvature)
8. Compensating for labile blood pressures
**no cure for FD and death occurs in 50% of affected individuals by age 30

Therapies Under Investigation

In cell lines derived from heterozygous carriers of FD who display a normal phenotype, there are decreased levels of the normal or wild type IKAP transcript and also functional IKAP protein respectively.

This would suggest that increasing the amount of the wild-type IKAP transcript may improve the manifestation in patients with FD.

Application of tocotrienols in the treatment of FD elevated the expression of IKAP transcripts as well as the amount of induced functional IKAP protein in homozygous cell lines derived from FD patients.

This observed result further suggests the value of therapeutic approaches to lessen suffered symptoms of FD patients by elevating cellular level of functional IKAP which can be induced by tocotrienols

One form of therapy under investigation is electrolyte therapy for refractory seizures common among FD carriers, such as the product Ceralyte.

Child behavior in a pediatric dental practice associated with types of visits, age and socio-economic factors

Resident’s Name: Laura Randazzo Sabnani Date: September 5, 2008
Article title: Child behavior in a pediatric dental practice associated with types of visits, age and socio-economic factors
Author(s): Brill W
Journal: The Journal of Clinical Pediatric Dentistry
Volume (number): 25
Month, Year: 2000
Major topic: Patient behavior patterns in a private pediatric dental office
Minor topic(s:
Type of Article: Prospective study
Main Purpose: To describe child patient behavior patterns seen in a private pediatric dental office
Overview of method of research: 976 visits made by 539 patients during a period of three consecutive months. Patients were grouped new born-60 months (0-5), 61-96 months (5-8), 97-144 months (8-12), and 145 months and greater (>12). Behavior was scored using the Sarnat scale during 5 types of visits, new patient exams, periodic recare, restorative dentistry, orthodontic adjustment, and quick check observation.
Findings: New patients 0-5 referred by general dentists had patterns of behavior that were the same as new patients in general. No fee for service patients above the age of five were referred with Sarnet scores 345. 33% of Medicaid patients 5-8 received scores of S345. For restorative S345 was 75% for ages 0-5 and decreased to 4% for ages above 12
Key points/Summary : There is a relationship between patient behavior and the age of the patient, type of procedure, source of patient referral, method of payment and familiarity with the office. The younger the child and the more threatening the procedure, the more prevalent the negative behavior. Patients who are fee-for-service are more likely to have more positive behavior than Medicaid patients
Assessment of article: It is unclear as to whether it is males or females with the higher incidence of negative behavior 8-12. In one area of the article it states females and in the conclusion it states males. This article puts on paper obvious expected outcomes but may be a great read for someone who is not in our profession to have a better understanding of how children of different age groups typically act for certain procedures.

Histopathology of the pulp in primary incisors with deep dentinal caries

Resident’s Name: Derek Banks Date: October 31, 2008
Article title: Histopathology of the pulp in primary incisors with deep dentinal caries
Author(s): E Eidelman, M Ulmansky, Y Michaeli
Journal: Pediatric Dentistry
Volume (number): 14:6
Month, Year: Nov/Dec 1992
Major topic: ECC
Minor topic(s): Pulpal involvement of ECC
Type of Article: Histological analysis of extracted teeth
Main Purpose: Assess the rationale behind current treatment modalities by observing histologic change in carious teeth.
Overview of method of research: 53 extracted primary incisors from 22 children analyzed histologically. 24 had pulp exposures and 29 had no pulp exposures.
Findings: 69% of the teeth with no exposures showed normal pulps compared to 33% of those with exposures. Microabscesses were found in 33% of teeth with pulp exposures, and only 10% of those without exposures. 46 out of the 53 teeth showed vital pulps.
Key points/Summary: Some of the discussion was interesting. It talks about how pulpal involvement in teeth without exposures may be accounted for. A few of the hypotheses are: trauma can lead to pulpal involvement and necrosis, microscopic pulpal exposures undetectable to the explorer, and increased permeability of deep dentin due to greater number of tubules and increased tubular diameter (however dentin under a carious lesion is less permeable due to the production of dentinal sclerosis and reparative dentin.
Assessment of article: Very interesting. Good rationale for treating primary incisors rather than extract them.

Lowe’s Syndrome

Lowe’s Syndrome

Significant craniofacial and/or oral features:
Facial dysmorphisms such as frontal bossing, deep-set eyes, chubby cheeks, & fair complexion
Dental cysts and dysplastic dentin formation of the teeth are found

Etiology:
Uncommon, X-linked disease
Hereditary defect affecting males only
Alteration in OCRL1 gene prevents production of PIP2-5-phosphate enzyme.

Prevalence:
1 in 500, 000

Age of Diagnosis:
Bilateral cataract and severe hypotonia are present at birth, with renal characteristics becoming evident in the weeks following birth. Psychomotor dysfunction is evident in childhood. Behavioral problems evolve during adolescence. Enzymatic and molecular testing available for prenatal as well as post-natal diagnosis of disease

Factors that influence dental care or require dental intervention:
Prior to treatment of patient, a review of medications as well as kidney function should be obtained. Patient may be on medications for seizure management;
The largest barrier to care with a Lowe’s Syndrome patient is behavior management

Associated systemic conditions:
Eyes: congenital bilateral cataract present at birth in all patients
50% have glaucoma
Kidneys: Fanconi-type renal tubular dysfunction
CNS: hypotonia, neonatal areflexia, mental developmental delays

Recent advances:

Factoids:
Also called the oculo-cerebro-renal (OCRL) syndrome
Life span rarely exceeds 40 years

voice control: effects on children’s disruptive and affective behavior

Department of Pediatric Dentistry
Lutheran Medical Center

Name: Craig Elice Date: September 12, 2008
Article title: Dentists’ voice control: effects on children’s disruptive and affective behavior.
Author(s): Greenbaum, PE, Turner C., Cook EW., and Melamed BG.
Journal: Health Psychology
Volume (number): 9(5) 546-558
Month, Year: 1990
Major topic: Behavior Management—Voice control
Type of Article: Prospective study
Main Purpose: The study evaluated (1) whether loudness is a requirement for the use of voice control or is a normal tone equally effective, (2) if voice control reduces children’s disruptive behavior, and (3) the after treatment affect on children. Does long-term dental fear increase when punishment (voice control) is used?
Overview of method of research: Forty patients (23 male and 17 female) ages from 3.5 to 7 years scheduled for cavity restoration who were considered potential behavior problems and were treated by 3 pediatric dentists who use voice control in daily practice. Treatment was randomized into two groups, loud VC, and normal voice VC, and lastly if behavior was good, a non-experimental control. A pretreatment Children’s Fear Survey Schedule Dental subscale and a Self Assessment Mannequin test were given. Videotapes of the procedure were scored using a Behavior Profile Rating Scale to measure fear and disruptive behavior. At the end of treatment, dentists rated children’s fear and cooperation. After leaving the operatory, children again rated feelings using the SAM test.
Findings: The groups were evaluated statistically for age, gender, dentist voice modulation, pre treatment fear and pretreatment feelings. Their distributions were not significantly different. Post intervention behavior showed that the loud voice group was less disruptive then normal voice VC within two seconds after receiving loud VC, and lasting for the measured duration of 2 minutes. The SAM score measuring affect showed significantly greater pleasure and lower arousal (greater calmness) for the loud VC group. The dominance affect had no significance between groups.
Key points/Summary: VC was a highly effective punishment technique to reduce childrens disruptive behavior for ages 3.5 to 7 years of age. Although one of the components of long term dental fear is a negative experience, this form of negative reinforcement did not elicit any long-term negative sequelae as measured by the SAM scores
Assessment of article: This study was able to integrate various psychological tests to determine the effectiveness of a commonly used technique in pediatric dentistry. It further validates the use of voice control in today’s pediatric dental practice .

Traumatic injuries to permanent incisors

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Derek Banks Date: August 22, 2008
Article title: Traumatic injuries to permanent incisors
Author(s): N Zerman, G Cavallari
Journal: Endodontic Dental Traumatology
Volume (number): 9:61-64
Month, Year: 1993
Major topic: Trauma
Minor topic(s): Trauma to permanent incisors
Type of Article: Retrospective chart audit
Main Purpose Analyze the prevalence of traumatic injuries to permanent incisors and their distribution according to type.
Overview of method of research: Case histories and radiographs were analyzed for 178 patients with injuries to permanent incisors (out of a total of 2827 cases reviewed), and data was recorded regarding severity of injury, common sequelae, and patient demographic data.
Findings: The majority of injuries to the permanent incisors occur between age 6 and 13. 80% of teeth involved were maxillary central incisors, and the majority of patients had some level of trauma to more than one tooth. Most common injury found in this study is uncomplicated crown fracture. PDL injury occurs in aprox. 40% of total. 48% had associated soft tissue damage. Alveolar fracture occurred in 12%.
Key points/Summary : People get hurt.
Assessment of article: Pretty good for some rough statistics.

Management of avulsed permanent incisors: A decision analysis based on changing concepts.

Department of Pediatric Dentistry Lutheran Medical Center
Resident’s Name: Joanne Lewis Date: 08/22/2008
Article title: Management of avulsed permanent incisors: A decision analysis based on changing concepts. Author(s): Jessica Y. Lee DDS MPH, William F. Vann Jr. DMD PhD, Asgeir Sigurdsson DDS Journal: American Academy of Pediatric Dentistry Volume (number): 23 Month, Year: 2001 Major topic: Management of avulsed permanent incisors. Minor topic(s): N/A Type of Article: Analysis Main Purpose: To present decision trees (flowcharts) for the management of avulsed permanent incisors. Overview of method of research: The decision trees were based on guidelines from the American Academy of Endodontics and incorporate some newer ideas and changing concepts. Findings: The two main complications of avulsed teeth are attachment damage and pulpal infection, so management and treatment should be aimed at minimizing these effects. Some interesting items from this article are: - If a tooth has been out of the oral cavity for greater than 60 minutes with dry storage, the periodontal ligament has no chance of surviving, meaning that ankylosis is certain. - When cleaning the tooth prior to reimplanting, scaling or scraping the root will remove any viable periodontal ligament cells. This may be desirable if ankylosis is predicted and the goal is to delay it as long as possible. An alternative is to soak the tooth in citric acid for three minutes. - After soaking the tooth in citric acid, it should be soaked in fluoride (APF or NaF) for 20 minutes - this has been shown to significantly reduce the rate of resorption. - Immature teeth that are soaked in a 1% Doxycycline solution prior to reimplanting have a greater rate of revascularization. (These studies were done in animals.) - For systemic antibiotics, Doxycylcine has been found to be the most effective in reducing inflammatory root resorption. Key points/Summary: The decision trees are presented in the article. Assessment of article: The decision trees are an easy, up-to-date reference for managing avulsed permanent incisors.

Sturge-Weber Syndrome (encephalotrigeminal angiomatosis)

Symptoms:
• Port wine stains of the face
• Glaucoma/exopthalmos
• Seizures
• Mental retardation
• Obesity
• Leptomeningeal angioma
• Convulsions and hypotonia on contralateral side of birthmark
Etiology:
• Sporadic with no hereditary tendency abnormal arteriovenous formation
• 1 in 14K births
• Due to overabundance of capillaries around the ophthalmic branch of the trigeminal nerve
• Retardation due blood vessel malformation in pia mater leading to calcification
Diagnosis:
• Usually diagnosed at birth with port wine stains on the forehead and upper eyelid of one eye and seizures.
• Treatment is symptomatic – laser treatment of stains and medications for the seizures
Dental Concerns:
• Medications to control seizures can cause gingival enlargement in addition to fibrous enlargement directly related to the disease
• Obesity can contribute to periodontal disease
• In many cases, altered eruption patterns and teeth resorbed by the pathologic capillary nexus growth can result in oligodontia.
• Intraoral angiomas
Recent Info:
• The size of the facial lesions have no correlation with the severity of the brain lesion
o Can J Neurol Sci. 2008 Jul;35(3):301-7
• Severity of seizures in early childhood and their surgical correction directly correlate to the extent of mental retardation in adulthood
o Dev Med Child Neurol. 2000 Nov;42(11):756-9.

Oral colonization of Streptococcus mutans in 6 month old predentate infants

Resident’s Name: Brian Schmid Date: Happy Halloween!
Article title: Oral colonization of Streptococcus mutans in 6 month old predentate infants
Author(s): Wan AKL, Seow WK, Purdie DM
Journal: Journal of Dental Restoration
Volume (number): 80
Year: 2001
Major topic: Mutans colonization in predentate full term and premature infants
Type of Article: Retrospective/Observational
Main Purpose: To determine whether the oral cavities of pre-term infants are more likely to be colonized by SM than full term infants, since earlier colonization typically leads to an increased caries rate which affects pre-term children more than full term

Overview of method of research: 172 pre-dentate, 6 month-old had their mouths swabbed for SM counts and returned for a re-evaluation 3 months later.
Findings: 50% of pre-term and 60% of full term infants harbored SM. This difference was not clinically significant. Upon return for a 3 month re-evaluation, every infected child showed a second positive culture. In both groups, infected children were more likely to do demand-breast feeding and slept next to their mothers. There was no difference in incidence of bottle feeding between infected and non-infected. Infection was correlated with starting earlier on solid foods. Non infected infants had a higher rate of daily gum cleaning and reported less chewing on adults fingers. Infected infants were more likely to have shared food with others or have their food pre-tasted. Infants treated with 5+ courses of antibiotics were less likely to be infected. Mothers with infected children were more likely to have higher levels of mutans, however the DMFS rating of the mothers was not different between mothers of infected and non infected children. Mothers with deep pocketing and visible plaque were more likely to pass it to their children. Low SES was also correlated with infection.

Key points/Summary : This article points out several important issues for prevention in neonates but roundly rejects the idea that prematurity alone is a factor for mutans colonization.

Assessment of article: Super!

Marfan Syndrome

Resident’s Name: Derek Banks Date: October 3, 2008

Syndrome: Marfan Syndrome
Incidence: Anywhere between 1:10,000 to 1:3,000 live births. It is panethnic and has equal distribution among males and females.
Etiology: Autosomal dominant. About 75% of those effected have a parent with Marfan Syndrome. The remainder are accounted for by spontaneous mutations. The fibrillin-1 gene encodes the glycoprotein fibrillin, a major building block of microfibrils, which constitute the structural components of the suspensory ligament of the lens and which serve as substrates for elastin in the aorta and other connective tissues. Abnormalities involving microfibrils weaken the aortic wall. Progressive aortic dilatation and eventual aortic dissection occur because of tension caused by left ventricular ejection impulses. Likewise, deficient fibrillin deposition leads to reduced structural integrity of the lens zonules, ligaments, lung airways, and spinal dura
Features (Craniofacial/Physical): Individuals with Marfan Syndrome have a characteristic “stretched” appearance, with elongated limbs and digits. Scoliosis is common, as is pectus excavatum. Typical facies include dolichocephaly, malar hypoplasia, enopthalmos, retrognathia, and downward-slanting palpebral fissures.
Features (Medical): Ocular findings may include glaucoma, cataracts, retinal detachment decreased miosis, and other ocular problems. Cardiac features include dilatation of the aorta (70-80%) and/or pulmonary artery that, when severe, requires surgical intervention to avoid aortic aneurysm (which is fatal). Mitral valve prolapse is present 55-69% of the time. Spontaneous pneumothorax can occur in 5% of individuals with Marfan Syndrome.
Dental Implications: Dental crowding and a v-shaped and/or highly arched palate are very common. This can, at times lead to a posterior crossbite. Most are class 2 (retrognathic), and may be more prone to TMD (anecdotal – no hard evidence of this). Appropriate medical consultations should be sent for these patients, as antibiotic prophylaxis may be recommended for these patients (The advisory board of the National Marfan Foundation says, regarding antibiotic prophylaxis for dental procedures: “given the propensity of individuals with Marfan syndrome formultivalvular dysfunction, myxomatous valve changes, and other cardiovascular disease and/or systemic illness that can predispose to infection or hamper recovery from endocarditis, and given the low burden and risk associated with the use of antibiotics for endocarditis prophylaxis, the Professional Advisory Board (PAB) of the NMF finds a compelling argument for the continued use of antibiotics in people with Marfan syndrome and valve dysfunction that is consistent with the spirit of the recent modification of AHA guidelines.” So despite the specifics given by the AHA, experts on the cardiac anomalies associated with Marfan Syndrome recommend antibiotic prophylaxis in most cases. Of note, if patient’s aortic distension is severe, and patient is at high risk for aortic aneurysm, an elevation in systolic BP can cause aneurysm to occur. Might not be a bad idea to have on hand a recent cardiology report and consider all measures that may help maintain the dental patient calm and BP low. Also, we may ask parents if the child is being followed by a team e.g. multiple specialists including genetics, cardiology, ophthalmology, pulmonology, psychology etc…
Recent Findings: If a patient has Marfan-like symptoms, or has been diagnosed with Marfan Syndrome, it is important we check to see if the patient has a bifid uvula. If they do, they may have a related syndrome called Loeys-Dietz Syndrome (a recently identified syndrome). Patients with this syndrome may have aneurysms in other areas in the arterial tree besides the aorta, and so management is different than that of Marfan Syndrome. As dentists, we may play a crucial role in the diagnosis of this condition (Loeys-Dietz) as well as Marfan Syndrome.
Miscellaneous/Summary: If we know what to look for we may aid in diagnosis. If we know what we’re dealing with, we can treat our patients safely. Either way we could very well be saving a life.

Management of the crying child during dental treatment

Resident’s Name: Anna Haritos Date: September 5, 2008
Article title: Management of the crying child during dental treatment
Author(s): Zadik, D, et al.
Journal: Journal of Dentistry for Children
Volume (number): n/a
Month, Year: Jan/Feb 2000
Major topic: parent’s attitudes towards their child’s crying during a dental visit
Minor topic(s): classification of crying types in children
Type of Article: scientific prospective study
Main Purpose: to present parents’ attitudes toward their child’s crying during dental care; to classify crying in children and relate it to management of the child
Overview of method of research: A questionnaire was distributed to 104 parents after their child had completed an initial dental evaluation and an additional operative visit. Parents were prepped on the range of behavioral approaches used prior to treatment. Parents were present in the operatories during dental treatment. The questionnaire addressed both parent and child’s demographics & prior dental experiences as well as parents’ education, occupation, preferred method of crying management used by the dentist, and what role they should play in managing the child’s crying. The dentist assessed the child’s behavior and tendency to cry at the end of the visit. Statistical analysis looked at the association between variables. A Chi-square test was run with a significance of P<0.05
Findings: When a child cried, most parents preferred the operator to pause treatment to calm the child down and then recommence when the child was relaxed. Most parents felt they should help the operator calm the child down. A significant difference was found in parents attitudes depending on if the child was male or female – parents were more inclined to help if the child was male. A significant association existed between a child’s Frankl behavior score and a tendency to cry. Parents were more likely than the operator to assess the child as ‘likely to cry’. Of the children in the study, 56% were males, 44% were females, and the age range was from 2-13 years of age. 82% of the children had had previous dental treatment and of these children, 70% had required pharmacological sedation. 48% of the children had fully cooperated with the previous treatment while 28 % were totally uncooperative previously. There was no significant association between sociodemographic variables of parents and the dependent variables.
Key points/Summary: A child can use fear as a catch-all and an excuse for misbehavior when there may be other explanations behind his/her actions. Elsbach defined four types of crying: 1) fear-motivated (w/hysterical behavior) 2) pain-motivated 3) compensatory-motivated, and 4) steady state siren-like. These authors present a new classification for crying, based on ‘the crying child’: 1) the child who communicates by crying (a) fearful, (b) resentful, (c) tension released; 2) the ‘cying type’; 3) the manipulative child. The authors propose the following operator approach to the above crying children: the first type is responded to with a soft, empathetic tone; the second ‘crying type’ is approached with a matter-of-fact tone while continuing with treatment; the third type of child should receive a matter-of-fact response but with a decisive attitude from the operator with indication that crying is allowed.
Assessment of article: Interesting approach to classifying crying; The age range seems to be too large a span but this may be a source of another study to see if there’s a breakdown in parental perception based on patient’s age.

How important are techniques? The empathic approach to working with children

Resident’s Name: Brian Schmid Date: 9/12/08
Article title: How important are techniques? The empathic approach to working with children
Author(s): John F. Roberts BDS
Journal: Journal of Dentistry for Children
Volume (number): 2
Month, Year: January-February 1995
Major topic: Review of behavior management philosophy
Minor topic(s: the use of empathy in pediatric behavior management
Type of Article: Review
Main Purpose: To reinforce the idea that it is the performance of a technique, not necessarily the technique itself that makes the difference between a success and failure.
Overview of method of research: Review and discussion.

Findings: The author reviews several non-pharmacological behavior management strategies and discusses how they can be properly and improperly used. The overarching philosophy is that we should be treating the child’s perception of dentistry as much as we are treating dental disease and their disquiet behavior. This is accomplished by assuming their outlook and acting empathically. By acknowledging their fear and addressing it, you can increase the effectiveness of a tried and true behavior management skills set, as well as performing more controversial skills in a way that will be more successful and acceptable to the patient and parent. For example, use of the Papoose board was almost universally panned until the Frankel approach, which included the help of the parent, redefined the social and professional view of the Papoose board. While Papoose use remains controversial to an extent, it has become more widely accepted by parents. The author does say that while empathy is a valuable tool to increase rapport, it is not always the absolute best bet. Children and dentists alike can act with selfish tendencies; including using empathy for alternate devices or simply for obtaining reward or avoiding punishment. “Empathy should not be an excuse for lack of management skills… We should not lack the confidence to deal with whatever emotion or behavior the child presents to us.”

Key points/Summary : The author emphasizes the use of empathy and understanding over rigorous and heartless implementation of learned behavior management. To allay fears and redirect their dental perception is the first step in pediatric behavior management.

Assessment of article: This was a very interesting, if not mildly wandering article which embraced empathy and the importance of compassion. It acts as a reminder that “Without compassion and authenticity, techniques fail.”

Estimation of caries-related risk associated with infant formulas

Resident’s Name: Laura Sabnani Date: October 16, 2008
Article title: Estimation of caries-related risk associated with infant formulas
Author(s): Erickson P, McClintock K, Green N,
Journal: American Academy of Pediatric Dentistry
Volume (number): 20:7
Month, Year: 1998
Major topic: Caries risk infant formulas
Minor topic(s):
Type of Article: Study
Main Purpose: To estimate caries-related risk associated with 26 infant formulas and whole milk
Overview of method of research: Adult volunteers were asked to rinse with infant formula and the pH was recorded before and after the rinse. Strep sobrinus was cultured in the infant formula and an increase in the colony forming units was measured. Powdered enamel was placed in each infant formula and incubated and the solubility was calculated in the absence of bacteria. The buffering capacities were determined by mixing standardized concentrations of acid. Enamel windows were created in primary incisors crowns that were exfoliated and extracted permanent molars and these were colonized with strep mutans and incubated with infant formula. For 18 weeks, caries were assessed visually and radiographically.
Findings: The average minimum change in pH in children was found to be 5.2-5.9. 9 of the infant formulas were found to be bacteriostatic, 8 were found to support bacterial growth and bovine whole milk was associated with one of the greatest increases in bacterial growth. Enamel mineral was dissolved by incubation with certain formulas in the absence of bacteria. Some formulas were unable to buffer the addition of acids.
Keypoints/Summary: Due to the cariogenicity of most infant formulas there is a need to educate parents about the association of ECC and infant formula.
Assessment of article: Interesting article with some great information for us to give to parents.

Multifaceted Use of ProRoot MTA Root Canal Repair Material

Resident’s Name: Dan Boboia Date: 8/22/08
Article title: Multifaceted Use of ProRoot MTA Root Canal Repair Material
Author(s): Don Schmitt, Jacob Lee, George Boen
Journal: Pediatric Dentistry
Volume (number): 23
Month, Year: 2001
Major topic: MTA’s physical / biological properties and the clinical techniques of direct pulp capping, apexification, and repair of failed CaOH therapy.
Minor topics: MTA composition and cost
Type of Article: Literature Review
Main Purpose: Review MTA’s physical and biological properties and the clinical techniques of direct pulp capping, apexification, and repair of failed CaOH therapy.
Overview of method of research: Review of literature pertaining to challenges encountered in direct pulp capping, physical properties / composition of MTA, and benefits of MTA use in procedures such as apexification, direct pulp capping, and repair of failed CaOH therapy.
Findings:
MTA has superior sealing ability to amalgam, ZOE, and IRM as well as superior characteristics as a direct pulp capping agent compared to CaOH in animal models.
The set compressive strength of MTA is equal to IRM and about (1/4) strength of amalgam.
Histological studies demonstrate MTA allows for regrowth of cementum when used in root perforation repair & new bone formation with minimal PA inflammation when used as root end filling material.
Stimulates release of cytokines and interleukin
Antimicrobial properties similar to that of amalgam, ZOE, SuperEBA
Setting uninhibited by blood or water / mixed with sterile water to for set up
Composition of MTA: calcium phosphate, calcium oxide, and bismuth oxide to achieve radiopacity similar to gutta percha.
Cost $300 / 5 grams
Direct Pulp Capping:
Case selection most important --- asyptomatic teeth testing normal to CO2 ice test or recent onset of mild sensitivity to chewing or temperature
Remove caries, irrigate with NaOCl 5-10 min, rinse out
Place 1-1.5mm MTA over exposed pulp, place wet cotton pellet over MTA, temporize with IRM or Photocore (no Cavit - absorbes water and can damage vital pulp)
Clinical success likely if hemostasis achieved 5-10 minutes of pulpal exposure using cotton pellet soaked in 5.25% NaOCl
Return 1 week, remove cotton pellet, test MTA set (same consistency as set concrete), assess vitality of tooth
Place final restoration over MTA
F/U 6 months to check vitality
Apexification:
Place rubber dam, remove pulp, clean root canals with NaOCl
Place CaOH in root canals 1 week to fully disinfect
1 week later rinse out CaOH with NaOCl and dry
Condense MTA to apex creating 3-4mm plug and check with radiograph
Place moist cotton pellet and close with IRM or Cavit
Restore case after 2 weeks (due to MTA’s excellent marginal adaptability and non-resorbable property)
Continual apexogenesis of immature root apices occurs with MTA
Can fill entire canal with MTA
Anterior teeth ---risk of MTA fill leaching toward clinical crown creating dark appearance.
Repair of Failed CaOH Therapy:
Case presentation of tooth #9 replanted & splinted 2hrs s/p avulsion
4 weeks F/U shows external resorption
CaOH placed
3 week F/U show increased resorption
CaOH removed, MTA placed with apexification sequenced described
7 weeks F/U showed healing resorption
10 months s/p original trauma external resorption ceased and PA lesion was healing
Key points/Summary : MTA is a material with numerous possibilities for pulp therapy
Assessment of article: Excellent reference article with clinical instruction for direct pulp capping apexogenesis, and repair of failed CaOH Therapy with MTA

Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth

Resident’s Name: Chad Abby Date: 8/22/2008
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Joe H Camp, DDS, MSD
Journal: Pediatric Dentistry
Volume (number): volume 30/ NO 3
Month, Year: May/ June 2008
Major topic: Vital Pulp Therapy
Minor topic(s): vital pulp therapy in primary teeth and immature permanent teeth
Type of Article: Literature Review
Main Purpose: This article reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apex.
Overview of method of research:
Findings: Apical closure cannot usually be determined radiographically (except for centrals and laterals) – the x-ray beam is exposed in the faciolingual plane, but the radiograph is read mesiodistally and the faciolingual width of most roots and canals is greater than the mesiodistal width. Therefore the clinician must rely on time to determine root closure. Diagnosis of pulpal status in Primary Teeth: Pain usually accompanies pulpal inflammation – provoked pain that stops after removal of causative agent usually indicates reversible and minor inflammatory changes. Spontaneous pain is constant or throbbing that occurs without stimulation and is indicative of pulpectomy or extraction. Electric pulp tests and thermal tests are not valid in primary teeth. Bitewings are best to diagnose pathological changes in primary molars. Calcified masses are indicative of advanced pulpal degeneration and are candidates for only pulpectomy or extraction. Internal resorption in primary teeth is always associated with extensive inflammation and must be extracted. The size of a pulpal exposure and the amount and color of hemorrhage are important factors in diagnosing inflammation. Deep purple colored hemorrhage or hemorrhage that cannot be controlled after 1-2 minutes of light pressure are candidates for pulpectomy or extraction. Primary teeth typically displace during injury rather then fracture due to shorter roots and might heal normally without sequelae by formation of an amorphous diffuse calcification, formation of a partial or complete obliteration of the canal, or result in pulpal necrosis. In a study of traumatized primary maxillary incisors 53% developed pulpal necrosis and 25% developed pulpal obliteration. *Studies have showed that no relationship between treating injured primary teeth compared with extraction regarding disturbance of the permanent teeth, although others have shown a tendency toward more extensive disturbances in mineralization when injured primary teeth were retained. Avulsed primary teeth should never be reimplanted. Color change of the tooth alone without other findings is not a reliable indicator of pulpal health – when diagnosis cannot be established it is justifiable to wait for further developments. Diagnosis of Pulpal Status in Permanent Immature Teeth: Every attempt should be made to preserve vitality – loss of pulpal vitality before dentin completion leaves a week root more prone to fracture. Provoked pain indicates pulpal inflammation of a lesser degree and is reversible as compared to spontaneous pain. Electric pulp tests and thermal tests are of limited value because of the varied responses as roots mature. Radiographic examination and interpretation are key elements in the diagnosis of pulpal pathology in teeth with developing apices. Yellow discoloration is usually indicative of pulp space calcification, and a gray color signifies pulpal necrosis. Transient apical breakdown occurs after displacement injuries and is linked to the repair process and will return to normal after healing complete – allow for adequate healing time. The use of calcium hydroxide for pulp capping and pulpotomy procedures in permanent teeth is being replaced with composite resins and MTA. The use of MTA as an apical barrier has become the standard for treatment of the open apex pulpless tooth. Revascularization of teeth with necrotic infected canals has been reported by using combinations of antibiotics.
Key points/Summary: The decision to render conservative vital treatment to allow root formation completion or more radical treatment such as root canal therapy might hinge on our diagnosis of root development. In permanent teeth, root formation is not completed until 1-4 years after eruption into the oral cavity. During the formative years treatments should be directed toward maintenance of vitality to allow completion of root formation. Immature teeth have the greatest potential to heal after trauma or caries, particularly when the apical foramen is wide open. If doubtful of treatment do not start, keep patient under close observation until adequate diagnosis can be made.
Assessment of article: Very good article – instead of going through this whole summary you probably should have just read the article! In fact the whole pediatric dentistry journal for May/June 08 is pretty cool.