The Consideration of Dental Development In Serial Extraction

Resident’s Name: Brian Schmid DMD Date: 10/2/09
Article title: The Consideration of Dental Development In Serial Extraction
Author(s): Conrad Moorrees DDS, Elizabeth Fanning DDS and Anna Marie Groen
Journal: ?
Month, Year: January 1963
Major topic: All you ever wanted to know about serial extraction but were too afraid to ask
Type of Article: Literature Analysis
Findings: Variance in tooth size and arch size determine the presence of spacing and crowding; crowding can occur in patients with less than average tooth size or larger than average arch size. This can become complicated when predicting tooth and arch size in the developing dentition. The mean size difference between permanent and primary maxillary incisors is 7.4mm in males and 6.mm in females, with arch breadth increasing only ~3mm. In the mandible, the average difference in M-D widths is 5.1 ni males and females. On average, when primary tooth spacing is included there is enough room for the maxillary incisors and nearly enough in the mandible, leading to mild crowding there. During eruption of the maxillary incisors, 50% of children did have some crowding. During the second stage of dental development, the eruption of canines and premolars, the maxillary intercanine width increases 2mm in the maxilla and decreases slightly in the mandibular. The pattern of exfoliation, the location of the mandibular 2nd premolar and the depth of intercuspation of the 6 year molars dictates how much of the leeway space may be lost by mesial drift. Predicting adult intercanine width is difficult from age 9 years to adulthood and can vary from 1.2 to 1.6mm. In general, ¾ of root length is developed upon eruption of canines and premolars, canine being slightly longer when they pierce through the gingiva. Therefore, deciduous molars should not be extracted before ¼ root development if the tooth is near emergence or ½ if not. Primary canines should not be extracted before ½ root development of the permanent canines or the 1st premolar has already erupted. While we can predict leeway space well using dental casts and radiographs, predicting growth of arch size is very tricky and variable. It is best to be as conservative as possible when considering serial extraction and to monitor eruption of permanent teeth as well as root formation to optimize orthodontic diagnosis and proper treatment planning.

Assessment of article: Very good article.

Physiological tooth migration and its significance for the development of occlusion

Dan Boboia

Article Review 10/2/09

Title: Physiological tooth migration and its significance for the development of occlusion

Author: Louis Baume

The Journal of Dental Research: August 1950, Vol. 29, #4

Major Topic: Assessing the relationship between the degree of overbite of the deciduous dentition and that of the mixed permanent dentitions and the factors responsible for transitory change, if any, from the deciduous overbite to the permanent overbite in the same individual.

Methods:

52 series of plaster casts were made before and after eruption the permanent incisors. Each cast was classified according to degree of overbite as checked from the lingual aspect of plaster reproductions in occlusion. Overbite was classified as slight, medium, or severe:

slight – incisal edges of mnd. 1^st incisors met the upper incisal 1/3 of the crowns of the opposing maxillary incisors

medium – lower 1^st incisors occluded with the middle 1/3 of the upper incisor crowns

severe – the mandibular incisors met the protuberance of the cingulum or came in contact with the gingiva

Measurements were made if the length of the frontal portion of the upper and lower arches in deciduous and mixed dentition.

Deciduous:

Slight OB: 40% cases

Medium: 29% cases

Severe: 31% cases

Mixed:

Slight:19%

Medium: 27%

Severe: 54%

Findings:

Data reveals that during the transition from a deciduous to mixed dentition a developmental tendency toward the formation of a deeper bite occurs.

Summary:

1) Degree of incisal OB in the permanent dentition primarily was determined by the extent of mandibular forward growth which occurred during the eruption of the successional teeth. The lessened forward extent of the mandibular arch was responsible for a greater incidence of severe overbite in the mixed dentures.

2) The deciduous overbite was also a determining factor in that the slight overbite tended to increase during the period of the mixed dentition while a severe overbite became worse.

3) The definite overbite of the permanent dentition finally depended upon the eruption sequence of the permanent canines and premolars. If in the lower arch the sequence was canine, first premolar, second premolar and in the upper arch first premolar, canine, and second premolar, the best results were observed.

4) Incisal overbite developed independently of the mechanism of molar adjustment.

Assessment:

Well written; a good read!

Orthodontics and temporomandibular joint internal derangement

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 9/18/2009
Article title: Orthodontics and temporomandibular joint internal derangement
Author(s): Katzberg RW, Westesson PL, et al.
Journal: Am J Orthod Dentofac Orthop
Volume (number): 109:515-20, 2006
Major topic: MRI’s of TMJ in symptomatic vs asymptomatic patients
Type of Article: Research article
Main Purpose: This study compared prevalence of internal derangement of the disc in TMJ of a symptomatic volunteers vs. symptomatic patients and to further compare them for a positive history of orthodontic treatment
Materials and Methods: 178 subjects were included in the study. 76 (39 female and 37 male) were asymptomatic volunteers and 102 (90 female and 12 male) were TMJ patients. An exam and history of TMJ pain, clicking, or tenderness were performed on all patients. An MRI of both TMJ’s in all patients were evaluated for disc displacement with and without reduction.
Findings: 25(33%) volunteers and 79 (77%) patients had at least one abnormal TMJ. Bilateral internal derangement was noted in 14% of volunteers and 51% of patients. The most common type of TMJ displacement was anterior displacement. A history of orthodontic treatment was present in both asymptomatic volunteers and TMJ patients. 33% of the asymptomatic volunteers with a normal TMJ scan, and 24% of the volunteers with anterior disc displacement had prior orthodontic treatment. In TMJ patients with anterior disc displacement, 20% had orthodontic treatment. In these symptomatic patients with a normal TMJ, 23% had orthodontic treatment. There was no relationship between asymptomatic and symptomatic patients and orthodontic treatment nor with disc displacement. Of note was a higher prevalence of TMJ displacement in asymptomatic volunteers then expected. As expected, there were significantly higher numbers of internal derangement amongst TMJ patients. A possible explanation for the higher then expected asymptomatic patients having disc displacement was that an MRI is more sensitive instrument in detecting the displacement. Lastly the data supports a very high prevalence in female as compared to males.
Key points/Summary : In summary, no relationship was found between orthodontic treatment and TMJ internal derangement.
Assessment of article: Good article that supports much of what Giannelly has spoken about in the past.

Physiological Tooth Migration and its significance for the development of occlusion: The Biogenesis of Accessional Dentition

Resident: Roberts
Article title: Physiological Tooth Migration and its significance for the development of occlusion: The Biogenesis of Accessional Dentition.
Journal: From the Division of Dental Medicine, College of Dentistry, and The George Williams Hooper Foundation for Medical Research, UCSF
Pages: 331-337

Background: The “accessional dentition” makes its appearance with the eruption of the first permanent molars which are guided into position by the distal surfaces of the second deciduous molars.

Distal step: described as the mesial portion of the primary mandibular second molar being distal to that of the mesial portion of the primary maxillary second molar.
End to End: described as the mesial portion of the primary mandibular second molar being flush with the primary maxillary second molar.
Mesial step: described as the mesial portion of the primary mandibular second molar being mesial to the mesial portion of the primary maxillary second molar.

Findings: 60 cases were studied using casts before and after the eruption of the six year molars into occlusion.

Through comparative measurements, three different biologic mechanisms of normal occlusal adjustment of the accessional dentition were found:
1. The occurrence of a terminal plane forming a mesial step in the deciduous denture allowed the first permanent molars to erupt directly into proper occlusion without altering the position of the neighboring teeth.
2. The presence of a mandibular primate space and a straight terminal plane was conducive to proper molar occlusion by means of an early mesial shift of the mandibular deciduous molars into the primate space upon eruption of the lower first permanent molar.
3. Closed deciduous arches and a straight terminal plane resulted in a transitory end to end relationship of the first permanent molars. Proper occlusion was effected through a late mesial shift of the mandibular permanant first molars subsequent to the shedding of the deciduous second molars.

Summary: Patients with End to end or mesial step occlusions of the primary dentition have the best chance of obtaining ideal class 1 occlusion in the young permanant dentition. They due this by one of three ways: First, having unobstructed eruption of the 6 year molars into ideal class 1 occlusion. Second, by having permanent mandibular first molars push the deciduous second molar into the primate space until proper class 1 occlusion is achieved. Lastly, if no primate space is available then the 6 year molar slides forward into ideal class 1 occlusion once the deciduous second molar has been exfoliated.

09/25/2009 The six keys to normal occlusion

Resident: Hencler
Date: 09/25/2009

Article title: The Six keys To Normal Occlusion
Author(s): Lawrence F. Andrews, DDS
Journal: Am. J. Orthod.
Volume #62; Number 3; Page 296-309
Year: 09/1972

Major topic: Occlusion
Type of Article: Observational Study

Main Purpose: Identify and explore significant characteristics in non-orthodontic patients that constitute a normal occlusion.

Overview of method of research: Examine 120 study models of non-orthodontic patients to identify key characteristics that make up a normal occlusion. 120 study models were selected from patients which, have never had orthodontic treatment , had teeth that were straight and pleasing in appearance, and had a bite which looked generally correct, and would not benefit from orthodontic treatment.

Findings: The 6 keys to a normal occlusion were found to include 1) molar relationship 2) crown angulation 3) crown inclination 4) rotations 5) spaces 6) occlusal plane.

Key points in the article discussion:

• Key 1 molar relationship: The mesiobuccal cusp of the maxillary 1st molar occludes in the mesiobuccal groove of the mandibular 1st molar. The distal surface of the of the distobuccal cusp of the maxillary 1st molar occludes with the measial surface of the mesiobuccal cusp of the mandibular 2nd molar

• Key 2 crown angulation (tip): The gingival portion of the long axes of all crowns was more distal than the incisal portions. Normal occlusion is dependent upon proper distal crown tip.

• Key 3 crown inclination (labiolingual or buccolingual inclination): Properly inclined anterior crowns contribute to normal overbite and posterior occlusion. Anterior teeth have a slight labial inclination. Maxillary posterior teeth have a lingual crown inclination that is similar from the canines through the 2nd molars. Mandibular posterior teeth have a lingual inclination that increases from the canines through the second molars.

• Key 4 rotations: Teeth should be free of undesirable rotations.

• Key 5 tight contacts: Tooth contact points should be tight with no spaces.

• Key 6 occlusal plane: Normal models ranged from flat to slight curves of Spee. The author claims that a flat plane of occlusion should be a goal of orthodontic treatment because there is a natural tendency for the curve of Spee to deepen with time.

Summary of conclusions: The 6 keys to normal occlusion contribute individually and collectively to the total scheme of occlusion and are essential to successful orthodontic treatment.

Assessment of article: I thought this was an interesting article because this information is still relevant today. Occlusion is important in every aspect of clinical dentistry so it’s never a bad time for a little review.

Ethical issues in managing the noncompliant child

Resident: Murphy
Date: 09/18/2009
Article title: Ethical issues in managing the noncompliant child
Author(s): Griffin, Ann. Lawrence Schneiderman
Journal: Pediatric Dentistry 14, #3 1992
Major topic: How to manage the child who doesn’t want to consent to treatment
Type of Article: Clinical Case Review

Main Purpose: To discuss the ethical dilemma involved with why we should or should not treat a child who needs treatment, but will no consent to treatment

Overview of method of research: Descriptions of procedures were provided to 120 parents by one of 4 methods: 1) Video 1 of technique during live appointment with an accompanying explanation before video is viewed, 2) video 2 of technique without explanation, 3) written presentation, and 4) oral presentation.

Findings: One of the first things we all learn in dental school is that you don’t do anything without an informed consent, no exceptions. A proper consent should include a description of recommended techniques, benefits of the procedure, alternative tx options, and risks for not doing any treatment. This article discusses the dilemma of having a child who needs emergency dental treatment, but is noncompliant. Patient autonomy is a fundamental right of all patients. Because a child may not be able to understand the consequences of their choices, parents sometimes need to override their refusal. While children may refuse the necessary treatment due to fear, parents may refuse treatment of their child due to monetary reasons or insurance reasons. All of these pressures can compliment treatment and cloud what our primary focus should be; providing the best care for the child.
This article reviews five areas of consideration 1.tx indications, 2. patient autonomy, 3. benefits vs. risks of tx and no tx, 4. parents wishes, and 5. allocations of reasons($$$$).

Is the treatment needed right now?
When a patient cannot be persuaded to agree to treatment, we must decide on how pressing the dental needs are. If treatment is delayed could the patient be harmed? The article reviewed the case of a 3 yo girl with small occlusal caries on two lower teeth. After much coaxing, the child would not allow the dentist to perform any tx. While the dentist may feel it necessary to try to complete some type of treatment, because the needs are not pressing, it is best to postpone the tx, and try another day.

When should we disregard Patient’s right to refusal?
As stated previously, each case, and each child is different. The term “consent” is reserved for individuals with the full capacity to make independent decisions. By the age of 14 or 15, most adolescents have the decision making ability of an average adult. Depending on the child’s maturity and their dental needs, it may not be our right to force them to consent to tx, whether or not we agree with their decision.

Weighing Benefits and Risks of management techniques:
If the decision has been made to proceed to tx without consent of the child, the proper management techniques benefits and risks must be considered. Behavior management (or as we say now, guidance) is an art, and each practitioner has a variety of techniques that could be used to calm the child. The main goal is to provide the best tx possible while not physically or emotionally harming the child.

Parental approval:
When a patient is not old enough to make an informed decision, their parent can give consent for them as a proxy. A legal guardian can also act as a proxy. With that said, parents do not always act in the best interest of their children. When this happens, healthcare providers may be better equipped to decide for a child rather than self interested, incompetent, or uninformed parents. If the parents refuse the proposed tx, the professional should due their due diligence to attempt to educate and overcome the ungrounded fears or misapprehensions.

Allocating resources:
Sometimes the best treatment for a child is to be seen under GA. While this is what’s best for them, it may not feasible due to lack of money or insurance companies denying treatment. Dental problems are considered less serious than other procedures requiring GA. Therefore, third party companies often limit their coverage. This limitation on available options isn’t in the best interest of the patients, and compromises care. It’s up to us to advocate for these kinds of patients.

Summary of conclusions: As professionals, it is up to us to use our best judgment and weigh all of the variables in a given case when deciding what is best for a child. If a child has a large abscess and is in pain, all efforts should be made to get that tooth taken out. If the child has a small occusal, pushing treatment isn’t indicated. Basically think everything through, communicate effectively with parents and patients, give the child the best tx possible for today, and for their future dental visits.

Assessment of article: Good article, results not surprising. More common sense than anything.

Teenager's reality

Resident’s Name:  Joanne Lewis                                                            Date: September 18, 2009

Article title:  The teenager’s reality

Author(s):  David Elkind PhD

Journal:  Pediatric Dentistry

Volume (number):  9(4)

Month, Year:  December 1987

Major topic:  Psychology of teenagers

Type of Article:  Professional opinion

Main Purpose:  To review some of the realities constructed by adolescents as an aid to understanding their behavior.

Discussion:  Adolescence is a time of expanded logic and understanding (called the “second age of reason”) that is associated with an increased ability to conceptualize time and space as well as the outlook of others.  Teenagers are able to think about the thinking of others, but they routinely mistake what others are thinking about with what they are thinking about; the teenager has trouble taking the mental position of another person when it is different from his/her own.  Teenagers assume that everyone else is thinking about what they are thinking about, which is themselves.  This viewpoint allows teenagers to construct an “imaginary audience”, by whom they are constantly being observed, admired, or criticized.  This construct can have positive consequences – it can prevent people from behaving badly even when no one else is around, or serve as a motivator for personal success – and it can have negative consequences, as it makes teenagers particularly susceptible to peer pressure.  Teenagers also begin to develop the “personal fable”, which convinces them that bad things (drunk driving accident, unwanted pregnancy, etc.) can happen to other people, but not to them.  Teenagers are convinced that their experience is unique and couldn’t possibly be understood by anyone else (“you don’t know what it’s like to be in love!”).  Both the imaginary audience and the personal fable stay with us in an adapted (more moderate) form the rest of our lives and help us to deal with the challenges and risks of daily living. 

Key points/Summary:  The teenager’s actions are not guided by education or lack of it, but rather by their imaginary audience (peer pressure) and personal fable (belief of invincibility).  This sheds some light on why teenagers often make bad decisions and disregard known consequences.  It does no good to fully accept or deny these assumptions; rather, put them to the test.  For example, “Look, I don’t think most people will notice or care that you are wearing braces, but I could be wrong and you could be right.  Why don’t you wear them for a few days, and if people really do notice, then we can talk about which is worse, some temporary unpleasantness or a lifetime of crooked teeth?”

Assessment of article:  Interesting theories to put the reader in the mindset of a risk-taking, self-obsessed teenager.  Applying these theories may help the practitioner to motivate patients and increase compliance.

Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 9/18/2009
Article title: Managing Pediatric Dental Patients: Issues Raised by the Law and Changing Views of Proper Child Care
Author(s): Bross DC
Journal: Pediatric Dentistry
Volume (number): 26:2, 125-30, 2004
Major topic: Behavior Management Case Law
Type of Article: Editorial
Main Purpose: This article discusses legal issues relating to behavior management of pediatric dental patients and changing views of proper child care in a dental practice setting.
Materials and Methods: N/A
Findings: The laws relating to pediatric dentistry determine standards of care and also include changes in public expectations of reasonable care. The legal decisions can dictate how the standards of care change for pediatric dentists. Also reports of child abuse on mistreatment have sensitized patients and parents which necessitates that we make our decisions based on new research and thoughtful anticipation of improvements in care of children. Informed consent is evolving from the litigious 1960’s and 70’s to a document that represents “what a reasonable patient in the same or similar situation would want to know about the risks and benefits to the child before consenting to treatment.” Surveys indicate lack of use of informed consent for behavior management techniques and pharmacologic management. While it is agreed that many behavioral interventions are so benign as to not need consent, sedation and costs on the other hand need informed consent. Standards of care occasionally depart from what is acceptable to parents and pediatric dental patients like Hand Over Mouth Airway Restricted. Without an informed consent describing probability of success and risks of adverse effects, the dentist is at serious liability risk. Pharmacologic management has been shown to need informed consent. It is important that in the case of general anesthesia risks such as brain damage and death are listed even thought the probability is low. It is suggested that more research is needed to provide information about the effects of behavior management, as well as the safety of general anesthesia.
Key points/Summary : In summary, the author suggests that there is a change in paradigm from the dentists understanding of what is good for the patient to what the patient or parent deems acceptable. Research is needed to study evidence as to what is stated is good is actually good treatment. The goal is to provide the most benign treatment with the least negative consequences to achieve quality health care to children
Assessment of article: Poor article written by a lawyer with little or no knowledge of what it takes to treat children. I think that it is important that the dental clinician get involved in determining what is acceptable care so that legal bureaucrats do not mess things up.

Parents in the Operatory

Department of Pediatric Dentistry

Lutheran Medical Center

Kris Hendricks Date: 9-18-09

Article title: Parents in the Operatory

Author(s): Margaret A. Certo, DDS; Joseph E. Bernat, DDS, MS

Journal: NYSDJ

Volume (number):

Month, Year: Feb, 1995

Major topic: Presence of parents in the operatory during dental treatment

Minor topic(s: Changes in approach through time.

Type of Article: Professional paper.

Main Purpose:

To review the history of parental presence in the dental operatory, address changing opinions from early dentistry to present and lastly, make suggestions for guidelines to include parents in the operatory.

Overview of method of research:

Review of literature combined with professional opinion.

Findings:

Today, parents want to be with their children in the operatory and it is probably an inevitable that pediatric dentists will have to allow parents to be present during treatment. To make their presence a positive aspect of the treatment 7 recommendations are given (which can be reviewed in the paper).

Key points/Summary

In the past, parental presence was considered to have a negative effect on children’s behavior for dental treatment. Throughout the past hundred years, most studies have shown that there is little difference in children's’ behavior in the presence or absence of parents. Studies have argued both sides of the argument and make valid points on to both effects: on one hand, parental anxiety has been shown to negatively affect their children’s behavior at the dentist. However, it has also been shown that parental presence can have a calming affect on the patient.

The big deal is that today’s parents want to be with their children during treatment. Most parents feel strongly that they should be present during treatment. It is unlikely, moving into the future that parents can be excluded from the operatories.

Assessment of article:

I agree with the authors that parents should be allowed to be present during treatment of their children. However, I do not agree with this at St. Joes. Due to our set up, It is very crowded and uncomfortable to have parents present. It is also annoying to have nosey parents poking their heads into the treatment areas. What this article hardly addresses is the problem with siblings being allowed back. Just yesterday I had a bloody screaming mess on my hands only to look up and see some other kid standing at the foot of the chair watching. But, I don’t blame any parent for now wanting to leave other kids in our waiting room, and I can see why they don’t want to stay there themselves.

The use of imagery suggestions during administration of local anesthetic in pediatric patients.

Resident: Adam J. Bottrill
Date: 18SEP09 Region: Providence
Article title: The use of imagery suggestions during administration of local anesthetic in pediatric patients.
Author(s): Peretz B., Bimstein E.
Journal: Journal of Dentistry for Children
Volume #; Number; Page #s: July-August pp: 263-267
Year: 2000
Major topic: Behavior management
Minor topic(s): Hypnotism
Type of Article: Experimental study.

Main Purpose: To evaluate the effect of suggestion in a group of children before and during the receiving of a local anesthesia injection. Also, efforts were made to correlate these reactions with social and dental treatment variables.
Overview of method of research: Controlled study of effect of behavior management technique.
Findings: Not telling

Key points in the article discussion:

A. General: It is generally agreed upon that the most stressful time of a dental visit, for both patient and dentist is the administration of anesthesia (to a child).
1. “suggestion” is the main component in hypnosis
2. Found that the pulse rates of hypnotized children decreased and observed levels of crying were less intense.
3. Hypnosis is found, in general, to be more effective on younger children. It has been suggested though, that it not be used on those younger than 7 y.o.
4. Suceptability to suggestion:
a. females more than males
b. younger more than older
c. children of lenient parents more than children of strict parents.

B. Materials and Methods:
1. 80 children, age 3-16
2. All required anesthesia administration
3. Treated by one of two dentists:
4. Pre-data collected:
a. general behavior (relaxed, tense, highly tensed)
b. previous behavior (cooperative, uncooperative but allowing tx, uncooperative and didn’t allow tx)
c. mode of previous behavior management (non-pharmacological, nitrous, premed with nitrous, GA)
d. previous traumatic medical or dental treatment.
5. Behavior measured at current appt using previous measurements
6. Younger children told tooth was “going to sleep”, older children told the tooth would be “anesthetized”.
7. Before administration, all children was asked to think of their favorite pleasant image. Those who could not think of one were asked their favorite game/pet etc…
8. Throughout injection procedure, operator provided comments reinforcing the pleasant image.
9. Data collected:
a. whether they used the same image throughout, facial expressions, eye movement, body tonus.
10. Chi-square used for variable comparison, t-test used for boys vs. girls.

C. Results:
1. Mean ages: 5.3 boys, 7.2 girls
2. Nearly a third of the patients had previous dental/medical traumatic experiences.
3. 60% maxillary
4. 53% demonstrated facial pleasure, 31% indifferent, 16% dislike
5. 81% were “relaxed”
6. No gender difference found WRT eye movement, facial expression or body tonus.
7. Most children were able to maintain the images throughout procedure and most kept their eyes closed.
8. Those treated with nitrous or oral sedation were more able to maintain images.

D. Discussion:
1. Most children could conjure up images.
2. Boys (pets) were different than girls (nature) at what type of image they selected.
3. Present study agreed with previous studies that suggested younger patients are more susceptible to suggestion.
4. The request to “fantasize is a relaxation tool. The child is allowed to go into a light “trance.”
5. Good rapport is essential to this process.
6. Though many dentists use the power of suggestion intuitively, the findings of this study should encourage the routine and deliberate use of this technique.

E. Conclusions:
1. Visualization suggestions may be effective in children from the age of three.
2. The utilization of the child’s imagination is a baluable behavior management adjuvant during dental treatment.
3. Nitrous oxide enhances the children’s capacity to accept and retain images..

Assessment of article: Don’t we all sort of do this already? Seemed like a first year pedo resident project, but better organized. Shenanigans?