Drug-induced gingival overgrowth

Resident’s Name: Joanne Lewis Date: April 23, 2010

Article title: Mechanisms and management of gingival overgrowth in paediatric transplant recipients: a review

Author(s): Chabria D., et al

Journal: International Journal of Paediatric Dentistry

Volume (number): 13

Month, Year: 2003

Major topic: gingival overgrowth, Cyclosporine A

Type of Article: review of literature

Main Purpose: to summarize current knowledge concerning the etiology, pathogenesis, and management of gingival overgrowth.

Key points/Summary: Cyclosporine A (CyA) has been the primary tool to prevent transplant organ rejection in adults and children; one of the side effects of CyA is gingival overgrowth (GO). Studies suggest that children are more susceptible to CyA-induced GO than adults. The pathogenesis of drug-induced GO is unclear; some possible theories include: CyA alters the metabolism of human gingival fibroblasts, increased secretion by gingival fibroblasts, decreased phagocytic activity, a gingival inflammatory response to CyA, or increased gingival levels of plasma-derived growth factors. Factors affecting the severity of GO include: CyA serum concentration and dosage (association still unclear), age (children under the age of 5 at the time of transplantation experience the worst GO, probably due to immature fibroblasts), concomitant medication (nifedipine – administered to offset hypertension), oral hygiene. Management of GO: good oral hygiene, surgical intervention (little evidence for long-term efficacy), and pharmacological approach (improvement in GO has been seen following the administration of azithromycin, metronidazole, and clarithromycin). A new immunosuppressant agent Tacrolimus causes fewer oral side effects than CyA and is becoming more widely used in transplant patients.

Features of Severe Periodontal Disease in a Teenage with Chediak-Higashi Syndrome

Reviewed by Kris

Features of Severe Periodontal Disease in a Teenage With Chediak-Higashi Syndrome

I couldn't tell which journal this was from, but it was done in October 1999.

Authors: Delcourt-Debruyne, Boutigny, Hildebrand

Case report of a 14yr old pt with Chediak-Higashi (C-HS)

Chediak-Higashi: defect of neutrophil function. The syndrome includes oculocutaneous albinism, photophobia, neurologic features, enterocolitis and recurrent infections.

Oral findings can include severe periodontal disease. Often traditional treatment modalities are unsuccessful.

This patient had a history of early loss of deciduous teeth and early onset periodontal disease. The kid had mobility in all of his teeth. There was so much pain that debridement was difficult.

Take Home:

If you see a young kid with this level of periodontal disease, refer for immunological work-up, because there is likely a systemic cause.

Three case reports of aggressive periodontitis associated with Porphyromonas gingivalis(PG) in younger patients 4/23/10

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

Article title: Three case reports of aggressive periodontitis associated with Porphyromonas gingivalis(PG) in younger patients.

Author(s): Kawashima, Ishikawa, et al.
Journal: Journal of Periodontal Research
Year. Volume (number). Page #’s: 2002. 37. 324-332
Major topic: Bacterial culprits in aggressive periodontitis
Overview of method of research: Review of 3 cases

Findings: In 1999, the terms ‘early onset periodontitis’ and ‘juvenile periodontitis’ were replaced by the term aggressive periodontitis. Aggressive periodontitis is defined as a specific type of perio. that has been distinguished from chronic perio. LP and GP are characterized by rapid attachment loss and bone destruction.
At least three bacterial species, including AA, PG, and BF have been identified as etiologic agents of perio. in susceptible hosts.
In this report, the cases of 3 Japanese women, age 14, 24 and 27 were reviewed. Microbial analysis was completed on each case, and it was found that in each case, PG was the main bacterial component. BF was also found, however AA was not. Treatment included OHI, SCRP, and frequent recalls. At the recall visits, PG was not found in the subgingival pockets(although it was found in the saliva).

Key points/Summary:
-AA is not necessarily the lone ‘bad guy’ in young patients affected by AP
-PG can be integrally involved AP
-PG can be easily eradicated by conventional methods

Assessment of Article: Good article. No shenaynaygaaaans.

A clinical and research protocol for characterizing patients with hypophosphatasia

Resident: Adam J. Bottrill
Date: 23AAPR10
Region: Providence
Article title: A clinical and research protocol for characterizing patients with hypophosphatasia
Author(s): Hu, ChingChun et al.
Journal: Pediatric Dentistry
Page #s: pp. 17-23
Year: 1996, 18:1
Major topic: Hypophosphatasia
Minor topic(s): NA
Type of Article: Topic Review
Main Purpose: Review and discuss science behind, and clinical characteristics of hypophosphatasia (HP).
Overview of method of research: N/A

Key points in the article discussion:

I. General:
A. Usually autosomal recessive trait with prevalence of approximately 1 in 100,000 live births.
B. Highly variable clinical manifestations.

II. Underlying Genetic Defect:
A. Defect in gene-encoding, tissue nonspecific alkaline phosphatase (TNSALP).
B. HP occurs when a single nucleotide in the coding region for the protein is mutated, causing one of the 507 amino acids to change.
C. Dx with reduction in serum alkaline phosphatase activity and elevated serum and urine levels of TNSALP substrates.
D. There has been one documented case of “pseudo AP”.
E. Most severe forms of AP are recessive and usually lethal at or near birth.

III. Clinical Manifestations of TNSALP Mutations:
A. Classified according to age it first manifests itself. Usually the earlier the appearance of symptoms, the more severe it is.
B. Four clinical varieties: perinatal, infantile, childhood and adult onset..
1. Perinatal: occurs in utero with stillborn or death soon after.
2. Infantile: Similar skeletal deformities, but less severe. Dx based on radiograph. Flail chest, pneumonia, blue sclerae, harlequin orbits, pathologic lid retraction.craniosynostosis, premature tooth loss. Ossification defects.
3. Childhood: often first Dx by the dentist. Rickets, small stature, waddling gait, partial or complete lack of cementum formation which leads to malformation of PDL. Both parents likely to have the serum/urine characteristics. Bony deformities.
4. Adult: premature loss of teeth, Hx of early primary tooth loss, enamel hypoplasia, craniosynostosis, pseudogout.

IV. Role of Pediatric Dentist:
A. Often the first member of a health care team to make a Dx.
B. Referral may lead to Dx and can be a strong tool.

V. Proposed Clinical Approach:
A. Patient and family Hx (pedigree), with serum and urine analysis.
B. Physical exam including Ht and Wt to follow growth. Pano to track tooth loss.
C. Tissue collection. Teeth that have been extracted or prematurly lost may be submitted for histological examination.
D. Blood and urine samples.
E. Recall

Assessment of article: Effective article, however not as “dentistry specific” as I’d hoped. However, through accurate description of future cases, we can track and better understand the disease. No shenanigans.

: Severe Periodontitis in a 5 year old Girl with Hyperimmunoglobulin E Syndrome 4/23/2010

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/23/2010
Article title: Severe Periodontitis in a 5 year old Girl with Hyperimmunoglobulin E Syndrome
Author(s): Tsang P, Derkson G, Et al
Journal: Pediatric Dentistry 27:1
Month, Year: 2005
Major topic: Severe periodontal disease in Hyperimmunoglobulin E Syndrome
Type of Article: Case Report
Purpose: This article describes a 5 year old female with probable Autosomal Recessive HgE Syndrome who had severe perio in her entire primary dentition.
Background: HIES a.k.a. Job’s syndrome or Buckley syndrome has an autosomal dominant and Autosomal Recessive form The AD form is recognized by an increased IgE, chonic eczema, recurrent skin abscesses, lung staph infections, and a typical facies of a prominent forehead, deep set eyes, broad nasal bridge, mild prognathism, scoliosis, joint hyperextensibility, and a decreased bone density leading to fractures. The AR form also has an increased susceptibility to severe fungal and viral infections and a higher incidence of vascular and infectious central nervous syndrome complications. A diagnosis is based on a NIH score. Management is based on prophylactic antibiotics, localdebridement and surgical incision and drainage. A limited number of studies showed delayed eruption of permanent teeth.
Discussion: The patient was the first born child of a Kurdish couple who were first cousins. In infancy, the child developed severe eczema which were complicated by recurrent staph aureus and Candida albicans supra infections. The patient also had recurrent otitis media, hospitalization 5x for pneumonia, 1x for Staph Aureus sepsis. At age 3, she developed severe HSV-1 gingivostomatitis, and shingles. Osteopenia led to 2 tibial fractures.Lastly she exhibited failure to thrive. Extraoral exam revealed dry cracked lips, eczema like dryness of cheeks. Intraoral exam showed a smooth tongue with deep fissures. Periodontal evaluation revealed red edematous rolled margins with bleeding on probing and pocket depths of up to 9mm on all primary teeth. The treatment plan involved extraction of all prmary teeth to prevent infection from developing as the secondary teeth erupted and to prevent development of pneumonia secondary to a dental infection. The author suggests that rapid perio disease is caused by the f=effects of highly virulent perio pathologic bacteria, deficient PMN leukocytes repnses, and an increase in potent bone resorbing cytokines and decrease in bone resorption inhibitory cytokines.
Conclusion: this is the first reported case of severe periodontal disease related to Hyper IgE syndrome. Other more typical features include recurrent skin and lung staph infections, chronic eczematoid dermatitis, and elevated serum IgE levels. Despite advances in our ability to diagnosis the disease, management remains the same with prophylactic antibiotic therapy, timely treatment of infections, and surgical inbervention as needed.
Assessment of article: Good article on a very rare condition.

04/23/2010 Prevalence of orodental findings in HIV-infected Romanian children

Resident: J. Hencler
Date: 04/23/2010
Article title: Prevalence of orodental findings in HIV-infected Romanian children
Author(s): Flaitz, DDS, MS et al
Journal: Pediatric Dentistry-23:1, 2001

Major topic: orodental findings in HIV-infected children

Type of Article: Observational

Main Purpose:
Assess the prevalence of orodental conditions in symptomatic HIV+ Romanian children.

Background:
One of the highest concentrations of children living with HIV is in Romania. They represent about 90% of all AIDS cases in Romania. Most were not infected through vertical transmission, but rather from HIV-contaminated blood products. The practice of micro-transfusions for neonates and reuse of contaminated needles in hospitals and orphanages accounts for the high HIV infection rate in Romanian children.

Overview of method of research:
Study population consisted of 173 HIV+ children who received dental care during an 8-day period from a volunteer American dental team. Med hx reviewed and screened for the need of antibiotic prophylaxis. Extremely moribund patients or ones with active TB were excluded from the study. All oral and perioral lesions, selected cutaneous lesions, permanent tooth eruption patterns, and primary and permanent dentition caries (dfs/dft, DMFS/DMFT) were recorded by 4 dentists.

Findings:
A wide variety of HIV-associated oral and perioral lesions were found. The most common manifestations included candidal infections, oral and perioral ulcers, salivary gland enlargement, NUG/PD, and linear gingival erythema. Viral-associated lesions found less commonly were labial molluscum contagiosum, oral warts, hairy leukoplakia, and herpes zoster. One or more oral/perioral lesions were found in 55% of children. Many of the children had florid cutaneous diseases due to their immunocompromised status. Dental caries in both the permanent and primary teeth were considerable. Post-op complications were noted most often with EXT due to delayed clotting as a result of HIV-associated idiopathic thrombocytopenia purpura (ITP).

Key points in the article discussion:
Candidiasis is a well recognized indicator of immune compromise and in HIV infection is a prognostic indicator of progressive disease. This was the most common oral disease in the Romanian children with almost 1/3 affected. Documented risk factors for the development of oropharyngeal candidiasis include failure to thrive, lack of anti-retroviral drug use, low CD4, and immune suppression. The occurrence of oral and perioral ulcers was similar to a 3 year longitudinal US study and included herpes labialis, aphthous stomatitis, and necrotizing stomatitis. Dental caries was considerable in both the permanent and primary dentitions. Although caries prevalence in Romanian children is markedly higher than that for the US and Europe, the HIV+ children had an even greater extent and severity of caries than their non-infected counterparts in their own nation. Both delayed eruption of the permanent teeth and over-retention of primary teeth were common findings in this study. A major concern in providing dental care for HIV-infected children in developing countries is lack of available laboratory test, especially hematologic screenings. It was discovered that delayed clotting following EXT was a common occurrence, which required close f/u. ITP secondary to HIV infection was associated with hemorrhage following EXTs. ITP can be the result of antibody-mediated platelet destruction or bone marrow failure.

Summary of conclusions:
The oral health needs of HIV infected children in developing countries are considerable, ranging from rampant caries to a wide variety of mucocutaneaous infections. Although most of these children can tolerate dental procedures, the potential risk for post-op bleeding complications is a concern when surgical procedures are required.

Assessment of article:
Good article, very sad story. The high prevalence of HIV+ children in Romania and the poor medical practices that have contributed to the spread of HIV to these children is shocking. This is a very sad situation to say the least.

Prepubertal periodontitis: A review of diagnostic criteria, pathogenesis, and differential diagnosis 4/16/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title:Prepubertal periodontitis: A review of diagnostic criteria, pathogenesis, and differential diagnosis

Author(s): Watanabe, Keiko
Journal:
Year. Volume (number). Page #’s: 1990. 25. 31-48
Major topic: Prepubertal periodontitis(PP)
Minor topic(s):Clinical conditions presenting with signs/symptoms of PP
Main Purpose: Review the signs/symptoms of Localized PP (LPP), and generalized PP (GPP)
Overview of method of research: Varied case review, Review of literature(from 20 years ago)

Findings: Prepubertal periodontitis is essentially periodontitis of primary teeth, and may include gingival inflammation, early loss of primary teeth, and bone loss. PP MAY continue and appear in the adult dentition as periodontitis. PP is usually associated with a child who has some kind of underlying medical condition, including but not limited to neutropenia, hypophosphatasia, papillon lefevre synd, and acrodynia. However, PP can also occur in otherwise healthy children, although these kiddos do NOT suffer from bone or attachment loss. In 1983, page classified PP into two categories, LPP, and GPP. LPP is a localized form of PP, occurred in apparently otherwise healthy prepubescent children. GPP, the generalized form of PP occurs in children who had histories of delayed umbilical cord separation, delayed wound healing, persistent peripheral blood leukocytosis, cellulitis w/o pus, and various other serious infections. GPP has been identified as an oral manifestation of leukocyte adhesion deficiency(LAD).
The onset of both forms of PP is during or immediately following the eruption of primary teeth. LPP affects a various number of teeth, and the gingival inflammation is not as pronounced as expected. GPP affects all of the teeth, and presents with severely inflamed, erythmatous gingival.
There are many theories on why children get PP, ranging from a genetic disposition to numerous methodological factors. Possible etiologic factors include pathogenic bacteria, particularly A.A, bacteriodes intermedius, b. gingivalis, capnocytphagea,and e. corrodens. Sites with PP which had undergone bone loss showed evidence of infection with these culprits, especially AA.

Diseases associated with PP
Hypophosphatasia- Low levels or deficiency of alkaline phosphatase. Children who have HP present with premature loss of primary teeth(the most diagnostic factor), usually being the incisors, and possibly enlarged pulp chambers.

Papillon-Lefevre Syndrome(PLS)-Genetic autosomal dominant condition, child will present with hyperkeratosis of the palms and soles and periodontal destruction. PLS effects the majority of teeth in both the primary and permanent dentition. Symptoms include severe gingival inflammation and alveolar bone loss.

Neutropenia-Defined as a decrease in the number of PMN’s in the peripheral blood below certain values. Oral manifestations include severe gingival inflammation, ulcerations, and necrotic lesions anywhere in the oral cavity. Bone loss and early exfoliation are possible signs as well.

LAD-Autosomal recessive condition in which the expression of Mac-1. LFA-1, and p150,95 glycoprotein is severely depressed. Recurrent bacterial infections, impaired wound healing, severe gingival inflammation, gingival proliferation, cleft formation, and severe bone loss leading to early loss of primary teeth are clinical signs of LAD.

Chediak Higashi Syndrome(CHS)- Rare autosomal recessive disease in which leukocyte defects are associated with impared function of cytoplasmic microtubules, or microtubule assembly in PMN’s. Oral signs are severe inflammation, attachment and bone loss.

Leukemias-Group of conditions characterized by progressive uncontrolled proliferations of WBC’s. Oral signs include gingival bleeding, petechia, lymphadenopathy, gingival hyperplasia, hypertrophy, pallor, and alveolar bone resorption.

Acrodynia- Rare disease characterized by many clinical symptoms including gingival and mucosal hyperplasia, alveolar bone loss, early loss of primary teeth, loss of hair, and cramps.

Juvenile Diabetes- Decrease in insulin secretion or availability. Clinical oral signs include severe gingival inflammation and periodontitis and impaired wound healing.

HIV-Unusual gingivitis with diffuse erythema, gingival lesions similar to an atypical form of NUG, and rapid bone loss.

Treatment
LPP cases have been treated by either curettage followed by a standard child’s dose of penicillin for 5 days, and recare every 4 months.

For GPP, a consult with the physician is necessary to discuss the treatment options, which can range from curettage and AB therapy, to serial extraction.

In either case, it is advised that a CBC w/ diff, cell morphology, serum AP, and fasting glucose level is ordered.

Assessment of Article: Long, but helpful article. Lots of extra information on the different syndromes.

Growth and Development Considerations in the Diagnosis of Gingivitis and Periodontitis in Children

Resident: Adam J. Bottrill
Date: 16APR10
Region: Providence
Article title:
Author(s): Enrique Bimstein and Lars Matsson
Journal: Pediatric Dentistry
Page #s: 186-191
Year: 21:3, 1999
Major topic: Periodontitis and gingivitis in children
Minor topic(s): NA
Type of Article: Topic Summary

Main Purpose: This topic summary is intended to point out certain areas of the clinical exam where the pediatric dentist should practice extra vigilance in order to differentiate between pathologic processes (periodontisis and gingivitis) and normal periodontal growth and development.

Overview of method of research: Summary of articles.

Key points in the article discussion:

I. Overview
The relative lack of information regarding periodontal pathosis in children, some pediatric dentists may be forced to rely on data that has been gathered from adult studies. It is becoming more obvious that this may provide inadequate data regarding this topic.

II. Conclusions:

A. Gingivitis:
-There is an age related tendancy to develop gingivitis (same amount of gingival plaque resulting in different degrees of gingivitis.

B. Bacterial composition of dental plaque:
-Different bacteria present in the gingival plaque of children vs. adults

C. Inflammatory cell response:
-Research supports the fact that age may actually have more of an influence then severity of the disease on serum AB levels.

D. Puberty:
-There is hormonal influence on the gingival inflammatory process concomitant to puberty.

E. Primary vs. permanent teeth:
-Junctional epithelium of primary teeth thicker than permanent teeth (less permiable).

F. Tooth eruption and exfoliation:
-It is possible that during eruption, the junctional epithelium may be compromised and more susceptible to bacterial infiltration.

G. Periodontitis:
-Localized prepubertal periodontitis has been studied mostly in syndromic patients or those with systemic disease. There are not many studies available for otherwise healthy children.

H. Apical migration of junctional epithelium:
-Apical migration is considered “normal” as there are many studies that support its existance through the growth and development of children.

I. Summary:
-Pediatric dentists should be aware of the age-dependant existence of periodontal changes in children. Considering these variables, we must be able to properly distinguish between periodontal pathosis and normal growth and development.

Assessment of article: Not bad Mr. Bimstein. Useful and informative. Organized well. NO shenanigans here.

gingival disease

Resident’s Name: Joanne Lewis Date: April 16, 2010

Article title: Dental Plaque-Induced Gingival Diseases

Author(s): Angelo Maricotti

Journal: Ann Periodontol

Volume (number): 4(1)

Month, Year: 1999

Major topic: gingivitis

Type of Article: review

Main Purpose: to define and classify gingivitis

Key points/Summary: The characteristics common to all gingival diseases are: signs and symptoms that are confined to the gingival, the presence of dental plaque to initiate and exacerbate the severity, clinical signs of inflammation, no attachment loss, reversibility by removing the etiology, and possible role as a precursor to attachment loss. 2 categories of plaque-induced gingival diseases are: those affected by local factors and those affected by local factors and modified by systemic factors. Systemic factors include systemic disease (diabetes mellitus, leukemia), malnutrition (scurvy), hormone fluctuations, or drugs.

Assessment of article: Basic information.

Generalized Prepubertal Periodontitis

Resident: Roberts
Date: 4/16/10
Article title: Generalized prepubertal periodontitis
Author: Gurel, et al
Journal: Journal of Clinical Periodontology
Volume: 23, pages: 1104-1111
Year: 1996
Discussions
Generalized prepubertal peridontitis is a rare clinical entity characterized by acute inflammation and proliferation of the ginigiva with rapid destruction of the alveolar bone.
4 cases were presented in this article. All of which had a decrease in peripheral blood nertrophil chemotaxis. Peripheral blood lymphocyte subpopulations were analyzed by double – colored flow cytometetry using monoclonal antibodies for the receptors CD2, CD3, CD4, CD8, CD19, CD29, CD45RA, CD56, CD11bCD18. Lymphocytes bearing CD3 receptors showed a significant decrease compared to those of the controls. Natural Killer cells were lowered in 3 of the 4 cases. All of the patients showed a higher increase in CD11bCD18 expression. The evaluation of CD11bCD18 receptor in peripheral blood leukocytes may be of help explaining the role of neutrophils in the pathogenesis of the disease.
Assessment: An okay artcle, I wish there was more information on the disease and less of the actual biochemistry.

Drug Induced gingival overgrowth

Review by Kris Hendricks

(sorry it's board time--time to study articles, not write about them)

authors: Dongari, McDonnell, Langlais

Published in Oral Surgery, Oral Medicine, Oral Pathology in October 1993

The point:

Certain Anticonvulsants, Cyclosporine, and other calcium channel blockers have been shown to produce gingival enlargement in susceptible patients.

The pharmacologic mechanism seems to be similar at the cellular level, but these drugs act on different target tissues.

The hyperplastic response is not well understood, but it could be from an alteration in collagen metabolism and other host cell response mechanisms.

Treatment:

Until science can provide more insight into this, treatment should consists of plaque control, professional debridement and resective gingival procedures.

My take:

There seem to have been several board questions over the years that have emphasized drug induced gingival enlargement.

The subgingival microflora in phenytoin-induced gingival hyperplasia

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/16/2010
Article title: The subgingival microflora in phenytoin-induced gingival hyperplasia
Author(s): Takada k, Sugiyama H. et al
Journal: J Periodont Res 38:477-81
Month, Year: 2003
Major topic: Bacterial flora of Phenytoin induced gingival hyperplasia
Type of Article: Research article
Purpose: This article evaluates the microflora of patients taking phenytoin and further studies the relationship between phenytoin induced gingival hyperplasia and the presence of black pigmented obligate anaerobic Gram negative rods.
Overview of method of research: Subgingival plaque samples were collected from 38 patients with phenytoin induced gingival hyperplasia, 7 patients with no gingival hyperplasia who received phenytoin as a control, and 37 patients with no history of phenytoin exposure as the blank sample. All 82 patients were between 16 and 35 years of age and were considered mentally challenged. Microbiological examination via selective media were used to determine levels of Strptococcus, veilonella, fusobacterium, actinomyces, and black pigmented obligate anaerobic Gram negative rods. Further identification of black-pigmented rods were conducted.
Results and Discussion: The data indicated that the incidence of black pigmented rods in the test group was significantly higher than those in the control or blank groups. Further evaluation identified the group of Prevotella intermedia to be the present in greatest amount in the test group. Phenytoin causes gingival hyperplasia in approximately 50% of patients taking the drug. Its mechanism of action is uncertain, but it has been suggested that phenytoin sensitive fibroblasts may be present. Phenytoin also effects the immune system by inducing lymphoid hyperplasia and lymphomas, as well as induces secondary drug immunodeficiency. It also causes a decreased sodium flux and cellular folic acid uptake. However, a bacterial inflammatory component is necessary for gingival hyperplasia to occur. In this study, phenytoin seemed to elevate the levels of black pigmented rods above the control and blank groups. In other studies it was also shown that phenytoin seemed to suppress streptococcus and actinomyces yet that was not the case in this study.
Conclusion: It was concluded that the bacterial flora was altered in subgingival plaque by phenytoin. Elevated levels of black pigmented rods, specifically Prevotella intermedia were found in these samples
Assessment of article: Good article, however, it did not show that Prevotella intermedia caused gingival hyperplasia, only that it was elevated in the experimental group.

14/16/2010 Risk factors for drug-induced gingival overgrowth

Resident: J. Hencler
Date: 14/16/2010
Article title: Risk factors for drug-induced gingival overgrowth
Author(s): Seymour, Ellis, Thomason
Journal: J Clin Periodontol 2000; 27: 217-223

Major topic: drug-induced gingival overgrowth (DIGO)

Type of Article: Review

Main Purpose:
review various risk factors that have been associated with DIGO. Identifiable factors can be considered under the following headings: age and other demographic factors; drug variables; concomitant medication; periodontal variables; and genetic factors.

Discussion:

Age: has been considered an important risk factor for drug-induced gingival overgrowth especially for phenytoin and cyclosporine. Early studies on the prevalence of phenytoin-IGO identified in teenagers were particularly at risk from this unwanted effect. Combo of younger age and poor OH seemed to predispose to severest level of gingival involvement. Age has been reported as a risk factor for cyclosporine-IGO. Nearly all the patients from these studies showed some form of gingival changes and the number of children w/ clinically significant GO was higher (52%) when compared to adults. In relation to DIGO, associations include phenytoin and the young, Ca channel blockers and the middle aged, and cyclosporine and a broad range of ages.

Gender And Race: Gender and race were not important risk factors in phenytoin IGO. Cyclosporin studies showed that males were at greater risk and greater severity than females. Males were also showed to be 3Xs more likely than females to develop DIGO when taking Ca channel blockers.

Drug Variables: Drug dosages tend to be a poor predictor of gingival changes. It would be more appropriate to relate dosage to body weight to obtain a significant interpretation of dosage and it’s relationship to DIGO.
Concomitant Medication: Polypharmacy has been suggested to increase the prevalence of DIGO but not the severity.

Periodontal Variable: Plaque scores and gingival inflammation appear to exacerbate the expression of DIGO, irrespective of the initiating drug. When ortho appliances impede cleaning then the prevalence of DIGO is high.

Genetic Factor: Fibroblast heterogeneity remains one of the key factors used to explain the variable response of the gingival tissues to the various DIGO. While cytochrome p450 variation may be a risk factor for DIGO it is totally impractical to assess this on a clinical basis

Summary of conclusions:
Risk factors for any condition are only meaningful if they exhibit both reliability and sensitivity. While it is possible to identify the severity of these effects relative to each other within a study, it is not possible to rank these or provide additional weighting for observations from different studies.

Assessment of article:
Not so much, article is 10 yrs old. This review presented much information about the 6 risk factors some pertinent to us, some not.

Review of monitors and monitoring equipment during sedation with emphasis on clinical applications 4/9/10

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

Article title: Review of monitors and monitoring equipment during sedation with emphasis on clinical applications
Author(s): The mack Daddy….Stephen Wilson, DMD, MA, PhD(playa hatin degree)
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 1995. 17:7 413-418
Major topic: Different monitors that can be/should be used during dental sedation
Overview of method of research: Review

Findings: How many monitors should be used during dental sedation? Which kind of monitors should be used. The correct answer is, it depends. The best, basic answer is that an operator needs to know their limits, be prepared to handle one level of sedation higher than they intend, and be able to work and understand their monitoring systems.

Pulse Oximetry-Gold standard for monitoring. It is used to measure the oxygen sat. in the blood(absorption and ratio of red and infrared light represent degree of hemoglobin o2 sat.), and heart rate. Patient movement, nail polish, pressure on the vessels can affect the pox’s reading. While it’s important to keep these variables in mind...TRUST YOUR PULSE OX!!! Don’t dismiss bogus readings immediately. It may be telling you something is wrong, very wrong. It’s extremely safe, easy to use, relatively quick with info, and give you vital information about your patient’s breathing...or lack there of. Pox’s can be placed on the fingers, toes, and even ear lobes.

Blood Pressure Cuffs- Records BP and heart rate. It’s important to use the correct size cuff, otherwise the readings will be inaccurate. It’s safe, easy to use, and gives quick, important info. Can be used pre-op, intra-op, and post op.

Capnography- Not widely used, and even less understood, a capnograph determines expired CO2. Main stream units are used for intubated patients, and side stream for non-intubated patients. A small nasal probe is inserted 2-3mm into the nasal aperture. It’s important that there is no blockage, or obstruction of the nasal piece(duh). It’s easy to use, provides rapid info, and gives you a direct determination of airway patency.

Precordial Stethoscope- Also called a “bell”, it gives you the sounds of the heart and lungs, depending on placement. These are simple to use, non-invasive, durable, and cheap. Most importantly, it gives you immediate feedback on the patients breathing. Seasoned veterans can predict laryngospasms seconds before they occur when using precords. Good stuff.

Key points/Summary: Dr. Wilson goes on to discuss how he believes that sedation “depth” should be redefined by the AAPD(in table 2 of the article he outlines his plan). He discusses how in the near future there will be new kinds of monitors, even using brain mapping functions along with other sensitive measures. At the end of the day, the practitioner who sedates children must embrace the concept and understanding of a continuous, multi monitoring system.

Assessment of Article:Good review of necessary monitors, how they work, and their clinical application. GO STEVO!!

Use of sedative agents by pediatric dentists: a 15-year follow-up survey

This is why St. Joes doesn't sedate. A remix of the super famous post-sedation video.

Department of Pediatric Dentistry

Lutheran Medical Center

Kris Hendricks Date: 04-08-09

Article title: Use of sedative agents by pediatric dentists: a 15-year follow-up survey

Author(s): Milton Houpt, DDS, PhD

Journal: Pediatric Dentistry

Volume (number): 24:298-294

Month, Year: 2002

Major topic: Sedation

Minor topics: N/A

Type of Article: Scientific Article

Main Purpose:

To survey the countries pediatric dentists to see how frequently practitioners are using sedation.

Overview of method of research:

Survey

Findings:

Compared to practitioners 15 years ago sedation is being used more frequently by pediatric dentists.

This is mostly due to a number of practitioners who are very heavy users of sedation.

Key points/Summary :

Most pediatric dentists are actually not using sedation regularly.

About half of pediatric dentists are using Nitrous less than 11% of the time.

80% of pediatric dentists are performing sedations less than 10% of the time.

80% of sedations were performed by 20% of the responding pediatric dentists.

Assessment of article:

The findings of this article are good news for those of us at St. Joe's where we don't believe in conscious sedation.

I would be interested to find out how often general dentists are sedating kids, since I know more general dentists

who regularly sedate children than I do pediatric specialists.

04/09/2010 Sedation in pediatric dentistry: a practical a practical assessment procedure

Resident: J. Hencler
Date: 04/09/2010
Article title: Sedation in pediatric dentistry: a practical a practical assessment procedure
Author(s): Moore Et Al
Journal: JADA, Vol. 109, October 1984

Major topic: Sedation techniques and assessment
Type of Article: Clinical Observational

Main Purpose:
Evaluate the safety and efficacy of a particular agent and develop an assessment tool that could be used by clinicians to assess their own sedation regimens

Overview of method of research:
assessment is limited to the preoperative period in which procedures are most uniform rating the behaviors as satisfactory or unsatisfactory. 60 pts (healthy pats age 2-5 needing tx requiring LA) who were considered uncooperative for routine dental care and who were to receive outpatient premed were recruited for study. Pts assigned to random grps A-D. (grpA20-grpB40-grpC60mg/kg chloral hydrate and grpD placebo). Each child was monitored by a single research assistant and rated 6 times b/f operative tx: (A)sedation behavior in quiet room, (B) sedation behavior on arrival to operatory, (C)airway patency b/f N2O, (D) sedation behavior in operatory after 3 min N2O, (E) airway patency after 3 mins N2O, (F) response to LA injection. The dentist who performed the operative provided behavior Frankl rating.

Findings:
Sedation behaviors of 20mg/kg grp were nearly identical to placebo. 40mg/kg grp tended to have more negative behaviors. 60mg/kg grp was statistically superior to the placebo.

Key points in the article discussion:
The risks involved in sedated children are related to a variety of factors. Toxic rxns are related to dose and must be considered when considered when selecting premedication treatment. Loss of consciousness can be seen at lower does than those that produce resp and cardio depression. Monitoring of consciousness, by checking response to command and protective reflexes, is an important requirement for the sedation of children. The practicioner should be prepared to control any adverse drug effects. It is essential that the resp and cardio functions be continuously monitored at all times and if need be maintained in the case of emergency.

Summary of conclusions:
Children receiving the placebo tx behaved favorably for at least 46% of the ratings; the 20 mg/kg and 40 mg/kg chloral hydrate grps showed little or no improvement when compared with the placebo grp; the grp receiving 60 mg/kg chloral hydrate had as much as a 33% improvement in behavior as compared with placebo and with the addition of 40% N2O/60% O2 to 60 mg/kg chloral hydrate premedication, four of 15 children (27%) were unalble to maintain a patent airway when intentionally obstructed.

Assessment of article:
Good article, Important info and good study that could apply to OCS.

Malignant Hyperthermia

Resident: Roberts
Date: 4/8/10
Article title: Malignant Hyperthermia
Author: Fortunato-Phillips, Nancymarie
Journal: Critical Care Nursing Clinics of North America
Volume: 12, Number: 2,
Year 2000, June

Discussions
What is Malignant Hyperthermia?
MH is a sudden pharmacogenic hypermetabolic crisis involving uncontrolled calcium release from skeletal muscle that causes potentially fatal consequences. It is triggered by administration of a depolarizing muscle relaxant such as succinylcholine, or a volatile inhalation anesthetic such as halothane, sevoflurane or desflurane. It has been shown to occur as an autosomal dominant train in families, thus each child of a person who is susceptible to MH has a 50% chance of inheriting the gene for this predisposition.

Pathophysiology of MH
A triggering agent causes uncontrolled release of calcium from the sarcoplasmic reticulum causing sustained muscle contraction and hypermetabolism. During this state, large amounts of oxygen and energy are being consumed resulting in an increase in carbon dioxide in the blood and the patient begins to take rapid deep breaths if he is not under the influence of neuromuscular blockade. The prolonged hypermetabolic state of muscular contraction causes rhabdomyolysis resulting in a release of free myoglobin that begins to build up as sludge in major organs, particularly the renal tubules which leads to renal failure. In addition serum potassium increases causing myocardial irritation resulting in sinus tachycardia and dysrythmias.

Signs and symptoms
The earliest sign of a potential crisis in process could be trismus noted during intubation, followed by increased end tidal carbon dioxide, ventricular dysrythmias and tachypnea.

Treatment
All inhalational anesthetics and depolarizing muscle relaxants are stopped and the patient is placed on 100% oxygen. The surgical site should be closed as quickly as possible. The body should be lavaged with cool saline. The drug, dantrolene sodium ,should be administered at a bolus rate of 2.5mg/kg – 10mg/kg until stabilization occurs. The patient should be placed in critical care and DS should be administered at 1mg/kg for the next 48 to 74 hours to prevent a relapse of MH.

Assessment

Good article!

Adverse Sedation Events

Resident’s Name: Joanne Lewis Date: April 2, 2010

Article title: Adverse Sedation Events in Pediatrics: A Critical Incident Analysis of Contributing Factors

Author(s): Charles J. Cote MD, et al

Journal: Pediatrics

Volume (number): 105 (4)

Date: 2000

Major topic: adverse sedation events in children

Type of Article: research article

Main Purpose: to examine the factors that contribute to adverse sedation events in children undergoing procedures.

Overview of method of research: 118 reports involving an adverse sedation event were reviewed for factors that may have contributed to the adverse event. Examples of some contributing events: drug overdose, inadequate monitoring, inadequate resuscitation, premature discharge, etc. The outcomes were classified as no harm, prolonged hospitalization without injury, permanent neurological injury, or death. 4 physicians examined reports; 95 reports for which the physicians agreed on the contributing factors and outcome were included in the final analysis

Findings: Patients sedated in a non-hospital setting were older and healthier than patients treated in a hospital setting. Respiratory compromise was the initial observed event in more than 80% of the cases; cardiac arrest was the 2^nd or 3^rd event much more frequently in patients treated in a non-hospital setting. Death or permanent neurological injury was the outcome more frequently in patients cared for in a non-hospital facility. Inadequate resuscitation was more common in management of nonhospital-based adverse events. There was a strong correlation between successful outcomes (no harm or prolonged hospitalization with no injury) and patients monitored with a pulse ox; this was especially true for the patients treated in a hospital. However, 4 out of 5 patients cared for in a nonhospital-based facility suffered death or permanent neurological injury despite pulse ox monitoring. 32 of the adverse events were dental related.

Key points/Summary: Uniform guidelines for monitoring children undergoing sedation should be in place, whether the patient is sedated in a hospital or non-hospital setting. Pulse ox monitoring should be used in all sedations. All health care providers who sedate children should have advanced airway management and resuscitation skills.

Assessment of article: Relevant.

Balancing efficacy and safety in the use of oral sedation in dental outpatients

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/02/2010
Article title: Balancing efficacy and safety in the use of oral sedation in dental outpatients
Author(s): Dionne RA, Yagiela JA, Cote CJ, et al..
Journal: JADA 137: 502-16
Month, Year: April 2006
Major topic: Workshop evaluating safety of sedation
Type of Article: Opinion paper from workshop. Literature review
Purpose: This article reviews the recommendations from a group of experts in anesthesiology, pharmacology and sedation at a workshop for the purpose of reviewing the scientific basis and status of oral sedation in dentistry and to further recommend areas needing further research and to make regulatory changes to improve patient safety.
Overview of method of research: A review of the litereature indicates that there is both a need for use of anesthesia and sedation to manage fear and anxiety in dentistry and an demand for the services. The degree of invasiveness/ stress of the procedure is directly related to the demand for sedation. The clinical practice of pediatric dentistry has evolved into three main areas of managing a pediatric patient depending upon the behavior of the patient. These three areas include behavior management techniques, sedation such as nitrous oxide, midazolam, and lastly general anesthesia. Based on the data supporting the safety of enteral sedation, the following was noted. Much of the data is deficient in quantification of morbidity and mortality due to under-reporting of adverse effects, over-reporting of adverse effects with new drugs, and incomplete documentation, lack of overall usage rates and changing clinical practice. However, the following conclusions were drawn from this data. They include excessive single or repeated doses should be avoided, multiple drug regimens should be used with caution, and lastly an understanding of each drugs pharmacologic properties and its combined effect with additional local anesthetic should be understood. Morbidity and mortality studies were reviewed. Ninety-five cases were reviewed with 60 resulting in death or neurological injury and 35 requiring prolonged hospitalizations or no harm to the patient. The most common cause was related to drug interactions or overdoses. All routes of administration were associated with deaths with the most common event being respiratory depression followed by cardiac arrest. Dentistry was associated with 29 deaths followed by radiology and cardiology. Pulsoximetry resulted in fewer deaths in a hospital setting but not in a private practice environment. The studies indicated that morbitidy and mortality was more related to monitoring and resuscitative skills of the provider more so that the drugs used, route of administration and patient population. It is believed that delayed recovery after pediatric sedation has not been well studied. The data indicate that strict discharge criteria with objective measures for discharge readiness should be considered. Bispectral index monitor continuously evaluates the patients electroencephalogram and computes a score from 0 to 100 which correlates well with depth of sedation and anesthesia in adults and children. The workshop discussed the pharmacokinetic activity of benzodiazepines more specifically triazolam which is a short acting, short half life sedation agent. Titration of the medication used orally is very difficult and frequently leads to complications. The Dental organization for Conscious Sedation (DOCS) protocol of multi dosing with Triazolam with nitrous oxide was discussed along with morbidity and mortality findings were presented. The review demonstrated the relative safety of benzodiazepines and the wide margin between therapeutic doses and toxic doses.
Conclusion: the general consensus of the workshop participants was that there is a strong need and demand for entereal sedation indentsitry. The oral route is convenient and widely accepted in dentistry.Additional prospective studies are needed to better assess the safety of enteral sedation. Increased education is key in promoting safe measures for administering enteral sedation.. Enteral sedation should be regulated by state boards to insure that dentists are properly trained and guidelines are followed when sedating patients in the office setting. As it relates to pediatric sedation, the workshop attendees emphasized the need for specific discharge criteria including making sure the patient can maintain their airway unassisted and remain spontaneously awake without stimulation. Lastly the participants felt the need to further understand the pharmacokinetics of flumazenil as it relates to reversing the actions of benzodiazepines, and to be qualified to use it if necessary
Assessment of article: It seemed like a very broad topic for a symposium. The summary of the workshop was very scattered from the discussion.

The physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients.

Resident: Adam J. Bottrill
Date: 02APR10
Region: Providence
Article title: The physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients.
Author(s): Leelataweewud, Pattarawadee et al.
Journal: Pediatric Dentistry
Page #s: 125-133
Year: 22:2, 2000
Major topic: Nitrous oxide use
Minor topic(s): Behavior management
Type of Article: Research article

Main Purpose: The study was performed to compare the effects of N2O/O2 vs O2 as adjuncts to an oral narcotics regimen for pediatric conscious sedation.

Overview of method of research: Randomized, double-blind crossover design

Key points in the article discussion:

I. Overview
A. 19 children sedated with chloral hydrate, iniperidine and hydroxyzine pamoate for two apts.
B. Randomly given O2 at one visit and N2O/O2 for the other.
C. Parameters: PR, RR, SpO2, ETCO2\
D. Procedures: mouth prop, anesthesia, rubber dam clamp, tooth prep,
E. Sedation success measured on scal of 0-3… 0=excellent, 3=aborted

II. Conclusions:
A. Although there were no differences in the physiological parameters for PR or SpO2, there was a small increase in RR in the N2O/O2 group.
B. N2O/O2 did NOT increase the risk of desaturation but did increase the frequency7 of desaturation events.
C. N2O/O2 deepened the level of sedation with this narcotic sedation regimen.
D. When N2O/O2 is used with this narcotics sedation regimen, child patients should be monitored with heightened vigilance and monitoring with capnography is recommended.

Assessment of article: Hmmmm…. Even though I’m only a PGY1… I could have saved Pattarawadee the time and effort of a fully-blown randomized, double-blinded study!!…. One word…Shenanigans.

Oral Midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 04/02/2010
Article title: Oral Midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study
Author(s): Nathan JE, Vargas KG.
Journal: Pediatric Dentistry Volume 24, Number 2
Month, Year: March/April 2002
Major topic: Midazolam and meperedine oral sedation
Type of Article: Retrospective Research article.
Purpose: this study evaluated the effects of different dosages of midazolam used alone or in combination with meperedine to manage difficult pediatric patients. The goal was to increase the time of sedation in the office while maintaining a safe conscious sedation state. This regimen has the potential of providing the amnesic and sedative qualities of midazolam with the analgesic and additive effect of the sedation of meperedine.
Overview of method of research: Patient sedation records of 120 moderately to severely apprehensive/ uncooperative patients, ages 24-48 months were reviewed. All patients received pre-treatment ratings for anxiety and cooperation potential which determined the dosage and type of medication used during the sedation. The author classified medication regimens as preventive doses to manage mild to moderate apprehension to management medication to manage more severe types of anxiety or negative behavior. The 120 patients were divided into 6 groups: Group 1 had 0.7mg/kg of midazolam, Group 2, 1.0mg/kg of midazolam, Group 3 had 0.7mg midazolam and 1.0mg/kg meperedine, Group 4 had 0.7mg of midazolam and 1.5mg/kg of meperedine, Group 5 had 1.0mg/kg of midazolam and 1.0mg/kg of meperedine, and Group 6 had 1 mg/kg of midazolam and 1.5mg/kg of meperedine. Success of sedation was determined by a sedation record assessment instrument developed by Nathan which rated sedation effectiveness in terms of rendering quality care to a patient with minimal or no interfering movement. Excellent or optimal sedation was defined as treatment permitted without restraint where patient remained responsive to verbal stimulation before, during and after sedation and was returned to the parent in full levels of responsiveness. Acceptable sedation was defined as occasional or persistent somnolence requiring mild physical stimulation to arouse, completed most of the treatment objectives, and minimal or limited restraint due to non-intentional interfering movements. Inadequate sedation and over-sedation are self explanatory. Mean heart rate was recorded at one minute intervals prior to and during the application of local anesthetic and cavity prep. Of further interest in this study was the effect of dosage on working time of sedation and also parental satisfaction with the sedation and post-operative recovery.
Findings: There was a statistical difference in ages between Group I and II and Group V and VI. No statistical difference was found between Groups II through VI with adequate sedation achieved in 80-100% of cases while Group I had excellent/adequate sedation in 40% of cases. Group V had the best results with 100% of patients receiving excellent/ adequate sedation. Heart rate changes were significant in Groups V and VI only during cavity preparation. In terms of safety, there were no episodes of persistent deeper sedation, but transient episodes of oxygen desaturation occurred in Groups II, III, and V and VI. Differences were noted in length of time before discharge in Groups IV, V, and VI with extended time needed for discharge in these groups. Working time was significantly better for Groups IV, V, and VI with Group I being ultra short. Parental assessment showed that most parents in all groups expressed approval and willingness to consider sedation again. The author noted that the addition of meperedine doubled the working time from 8±5 to 18±9 minutes.The author further noted that restraint was intentionally not used in order to better ascertain the effectiveness of the sedation. Restraint may mask the ability of the child to respond to noxious stimuli and therefore by eliminating restraint, we are removing a potential variable from this study.
Conclusion: In patients receiving only oral midazolam, the higher dose of 1.0mg/kg was significantly more effective. Adding meperedine seemed to improve the efficacy and duration of midazolam. Higher doses of the combination of midazolam and meperedine may increase the risk of deeper sedation and prolonged recovery.
Assessment of article: Good article but study was done retrospectively

Resident: J. Hencler
Date: 04/02/2010

Article title: A retrospective study of chloral hydrate, meperidine, hydroxyzine, and midazolam regimens used to sedate children for dental care
Author(s): Wilson
Journal: Pediatric dentristry-22:2, 2000
Major topic: Oral Sedation
Type of Article: Retrospective study

Main Purpose:
Examine the behavior and physiology of pre-school children each sedated with 1 of 3 drug regimens based on age, dental needs, and pre-operative clinical impressions and to determine the association between pre-operative behaviors to the behavior and physiology of the sedated children.

Overview of method of research:
Sedation sheets of 300 children were randomly selected from a pool of 600. Selection included preschoolers who had received one of the three drug regimens; chloral hydrate and hydroxyzine (CH-H), chloral hydrate, meperidine, and hydroxyzine (CH-D-H), or midazolam (M).

Key points in the article discussion:
M seemed to be consistent with quiet behaviors until the LA was administered at which time crying and struggling behaviors were observed. Heart rate was notably elevated during and after LA administration. Contrastingly, CH-D-M resulted in quiet and sleeping behavior after these procedures. CH-H was noted to be somewhere in between the other two regimens. The M regimen produced the least good behaviors compared to CH-D-H and CH-H. The M regimen has a short duration and occasionally causes “angry “child syndrome. M is ideally suited for short procedures, it has rapid onset when administered orally and causes minimal crying or struggling until 10-15 mins following LA injection. M has no analgesic properties. CH-D-H, contrastingly takes about 45 mins for onset and lasts 40 mins. It is often associated with a mellow affect during which interactive states and some analgesia are notable. It is a good combo of agents to use when 1 or more quads are required on a child who has potential reasonable coping skills. CH-H produced mild depressive effect consistent with settling of an anxious child. CH-H was not significantly different from the other 2 drug regimens.

Summary of conclusions:
• CH-D-H appears to maximize quiet and sleeping behaviors while producing more interactive and cooperative children.
• Children who pre-op follow instructions are minimally predictive of intra-op quiet and sleeping behaviors. Children who pre-op refuse to follow instructions were also minimally predictive of intra-op crying and struggling.
• Heart rate was consistent with age for all 3 regimens, however heart rate increased significantly following local anesthesia, reflecting disruptive and crying behavior in the M grp.
• Post-op heart rate, in addition to patient age, seems consistent with the degree of child cooperation and interaction with dental personnel. Uncooperative children had higher heart rates and BP pre- and intr-op.

Assessment of article:
Very interesting article. Some important stuff and would love to get some experience with oral sedation.

Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation 4/2/10

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

Article title: Factors Associated with Administration Route When Using Midazolam for Pediatric Conscious Sedation

Author(s): Primosch, Robert DDS. Fara Bender, DDS
Journal: Journal of Dentistry for Children
Year. Volume (number). Page #’s: 2001, July-August, 233-238
Major topic: Different ways to admin. Midazolam in the pediatric dental office
Overview of method of research: Retrospective chart study of 222 charts, containing 257 sedations. The children ranged from 15-82 months old. Children were either given intranasal or oral Midazolam, assessed pre-op, intra-op, and post op.

Findings: Midazolam (MD) is a benzodiazepine that possesses hypnotic, anticonvulsant, muscle relaxant, ante grade amnesia, and anxiolytic activity. It has been used in both medicine and dentistry for years. MD can be administered via IV, IM, and submucosal, intranasal, oral, and rectal routes, with each having it’s own advantages and limitations. IV administration is the best, however this can be quite hard to achieve due to lack of patient compliance. IV, IM and submucosal are painful to the child, and rectal is….well it’s rectal. Who wants to do that? Not this guy. Therefore the nasal and oral methods are the more commonly used delivery systems in dentistry. This article basically breaks down which route is better, intranasal or oral, and if preoperative behavior can be correlated with intra-operative behavior. Both have their pros and cons. Intranasal is easily administered (.18-.4 mg/kg), fast acting (10 minutes), and was associated with shorter treatment time than oral. Admin. However, 97% of the children who had the intranasal route were frightened, and described the experience of taking the MD as “horrible”. Also, children receiving intranasal MD were more combative, leading to more children being papoosed.
For oral admin, it’s easy to administer (.25-.75 mg/kg, mixed w/ 15mg ibuprofen or 1.5mg/kg vistaril), is relatively fast acting (20-30 min), and is usually better tolerated than the intranasal route. A con of oral admin is that it has an extremely bitter taste of the solution, even when mixed with other liquids.
The study found that compliance to oral drug admin did not correlate with cooperative behavior during treatment. This could be due to the psychotropic effects of MD, altering the child’s ability to cooperate, thus resulting in undesirable behavior. MD can cause dis-inhibition, eliminating or reducing the child’s ability to cope. Overall, behavior improved from pre-operative to intraoperative.

Key points/Summary: There were definite differences between each of the two methods of delivery. However, the are a number of variables that must be taken into account, including treatment history of the child, treatment style of the operator just to name a few. More research is needed to determine the predictive value of various parameters affecting pediatric sedation behavior management during dental treatment.

Assessment of Article: Some pertinent information that we all need to be aware of and think of when deciding whether to use MD, and which way to admin. it. Unfortunately, I found the article poorly organized, constantly contradicting itself, and non-committal.

Guidelines for Monitoring and Management of Pediatric Patients During and After

Title: Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures
Authors: AAPD Clinical Guidelines 09-10
Summary: Sedation of any kind should not be pursued by any provider who is not properly trained and experienced. The concept of rescue is essential to safe sedation and providers should have the skills to rescue a patient from a deeper level than that intended for the procedure. Minimal sedation (formerly known as ‘anxiolysis’): a drug induced state in which patients respond normally to verbal commands. Cardiopulmonary function is unhindered. Moderate Sedation (‘conscious sedation’ or ‘sedation/analgesia’): patient responds purposefully to verbal commands but perhaps requiring light tactile stimulus. No intervention is required to maintain a patent airway and spontaneous ventilation is adequate. If the patient is not making spontaneous efforts to open their airway, consider them deeply sedated. Deep Sedation (‘deep sedation/analgesia’): patients cannot be easily aroused but respond purposefully with repeated or painful stimuli (including sternal rub. These patients may require assistance in maintaining a patent airway.
Goals of Sedation: guard patients safety and welfare, minimize physical discomfort and pain, control anxiety, minimize psychological trauma, control behavior and movement so as to complete a procedure and to return the patient to a state in which safe discharge from medical supervision.
Potential for adverse outcome greatly increases when 3 or more agents are used (not including LA). You must be familiar with half-lives and titration, particularly knowing whether a dose of drug has taken effect before administering another. Common drugs with long half lives include: chloral hydrate, intramuscular pentobarbital and phenothiazines)è these require longer post op observation times, especially with infants and toddlers who are at risk for resedation due to lingering effects and potential for airway obstruction.
Candidates: ASA I and II patients are allowed for minimal, moderate or deep sedation. III and IV and those with additional airway complications should be considered for GA. A responsible person must be present whenever performing sedation, ideally a guardian and ideally 2 adults if it is a child, particularly those who are still in car seats. Facilities must have immediate access to and maintain equipment to deal with an obstructed airway. Back up emergency services must also be available for life threatening situations. On site monitoring and rescue equipment must also be present including a crash kit: airways, intubation materials, reversal agents, epipen etc. ECG, pulse oximeters, end tidal CO2 monitors and defibrillators must have a safety and function check on a regular basis.
Documentation: Informed consent. Instructions for the responsible person, especially concerning car seats. A 24 hour number should be available for all patients receiving sedation. Dietary precautions: ideally the same precautions for GA should be taken for sedation (see table). For emergency patients, the risk of sedation should be balanced against the value of the procedure and whether it can be postponed to when the proper dietary precautions have been taken. Immobilization devices should be used so that they do not obstruct the airway or restrict the chest. A foot or hand should always be exposed in case of need for venous access or O2 sat.
A thorough health history should be taken in order to determine eligibility for sedation as well as elucidate any additional risks a patient may present with. Be sure to inquire about herbal supplements which may have side effects such as inhibition of CYP450 (St Johns Wort, Echinacea) which may result in increased or decreased drug effectiveness. A health history should include all the basic information including a review of systems, vital signs and info concerning their medical home.
Prescription medications to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.
A “time out” must be performed immediately prior to treatment to confirm correct patient and procedure. After treatment, time and condition of child at discharge should be recorded including confirmation that the patient maintained proper O2 sats and consciousness in room air. A recent and popular technique for assuring recovery is that the patient can stay awake for 20 minutes in a quiet environment.
Setting Up:
· Suction of appropriate size
· Oxygen supply
· Airway management materials
· Pharmacy: rescue drugs including reversal agents
· Monitors: pulse ox, ECG, CO2 end tidal monitor, BP cuff, stethoscope as needed
· Equipment – special requirements
Minimal sedation require observation and intermittent assessment of their level of sedation. Practitioners must be trained in and capable of providing at the minimum, bag valve-mask ventilation so as to be able to oxygenate a child who develops an airway obstruction. Training and maintenance of pediatric airway skills is required.
Supportive personnel should be BLS certified and be able to support in any resuscitative attempts. Baseline vitals should be taken if possible. Practitioner must document the name, route, site, time and dosage of all drugs administered. Moderate sedation: O2 sat and heart rate should be monitored at all times. After moderate or deeper sedation, the patient must be monitored in a facility with proper suction and the ability to deliver 90%+ oxygen. Vitals should be taken intermittently and for the unconscious patient, O2 sat and heart should be continually monitored. Deep sedation: ECG and defibrillator should be present, vascular access should be achieved or at least the equipment and personnel to do so.
When administering LA, be sure to aspirate regularly as it can act as a depressant on the cardiopulmonary system. Capnography is valuable to diagnose the presence of breathing, airway obstruction or respiratory depression. The vast majority of sedation complications can be managed with simple maneuvers, such as supplemental oxygen, opening the airway, suctioning and bag-valve mask ventilation.
Assessment: Dense but important stuff. Know your limits.