Heart murmurs

Resident’s Name: Joanne Lewis Date: January 8, 2010

Article title: An Evaluation of Parental Concerns and Misperceptions About Heart Murmurs

Author(s): Brian W. McCrindle, MD, MPH, et al

Journal: Clinical Pediatrics, January 1995

Type of Article: research

Main Purpose: to determine the extent of anxiety and misperceptions about heart murmurs in parents of children referred for a cardiology assessment.

Overview of method of research: Parents of 182 patients who were referred for a first-time pediatric cardiology assessment due to a heart murmur were selected to participate in the study. Prior to the cardiology appointment, the parents completed a questionnaire that assessed the parents’ expectations, level of concern, perceptions about heart murmurs, and perceived vulnerability of their child. Parents whose children were diagnosed with an innocent heart murmur were mailed a similar follow-up questionnaire 1 month after their child’s clinic visit.

Findings: Of the 182 patients, 118 (65%) were found to have no heart disease (innocent heart murmur). In the preevaluation questionnaire, only 16% of parents correctly stated that a heart murmur was a sound made by the heart. 61% of parents perceived themselves to be more concerned than their referring physician (22% of parents rated themselves as extremely concerned). Extreme concern was related to the perceived level of concern of the referring physician. Of the 118 patients with an innocent murmur, 10% of parents still thought that their child had a heart problem after the cardiology assessment. The persistent perception by the parents that their child had a heart problem was related to lack of satisfaction with the visit to the cardiologist.

Key points/Summary: Awareness of the parents’ overall system of health beliefs and their perception of their child’s vulnerability to illness must be taken into account in targeting at-risk parents for counseling.

Assessment of article: Self-evident – any parent would be concerned if their child was referred for a cardiac assessment.

Dental abnormalities in children with chronic renal failure

Resident: Roberts
Date: 1/8/10
Article title: Dental abnormalities in children with chronic renal failure
Journal: Pediatric Dentistry
Volume#4 number 4
Pages 281 – 285
Discussion/Results:
17 children with Chronic renal failure were examined radiographically and clinically. Enamel hypoplasia was the most common abnormality (11 out of the 17); results inidicated that geographic location on the teeth corresponded to the age of onset of advanced renal failure. Completely developed teeth were unaffected by formation or mineralization if CRF set in after development. Mild and moderate renal failure did not present any serious effects on the maturation of the enamel. Discoloration and hypocalcification although present were in much fewer percentages.

Author hypothesized that careful supplementation of vit D and dietary phosphorus reduction may diminish hyperparathyroidism which may decrease the severity of enamel hypoplasia

Dental findings associated with the malformations of CHARGE

Resident: J. Hencler
Date: 01/08/2010
Article title: Dental findings associated with the malformations of CHARGE
Author(s): Sheneifi, Cottrell, Hughes
Journal: Pediatric Dentistry-24:1, 2002

Major topic: CHARGE

Type of Article: Review of literature and case report

Main Purpose: Present the non-random clustering of congenital malformations associated with CHARGE and the dental findings that are often observed with this condition.

Overview of method of research: Review and case report.

Background:
In 1979 a group of congenital anomalies was described and gave the acronym CHARGE representing:
• C: coloboma (hole) associated w/ the choroids, iris, retina or optic nerve.
• H: heart disease, which may include tetralogy of Fallot, septal defect or valvular stenosis
• A: atresia of choanae (back of nasal passage blocked by abnormal bony or soft tissue) which results in breathing difficulties and cyanosis in the first hr of life. Ultimately will require surgical opening.
• R: retarded mental development
• G: gential hypoplasia
• E: ear anomalies and/or deafness

A range of additional congenital abnormalities is now accepted to form part of the CHARGE association and include:
• Unilateral facial nerve palsey
• Orofacial clefts
• Renal abnormalities
• Characteristic facies (square face with malar flattening, pinched nostrils, and a prominent columella)

Dx of CHARGE requires at least 4 of 6 characteristics to be present. Abnormalities of CHARGE have been characterized as major, intermediate, and minor criteria. Major criteria are the findings that commonly occur in the CHARGE association but are rare in other conditions and Minor criteria occur less frequently, or are less specific to CHARGE. The etiology of CHARGE remains unknown although autosomal dominant and recessive inheritances are reported in sporadic cases. It is believed to occur in 1:10,000 live births. No teratogens have been implicated. Dental findings associated with CHARGE have been reported in a few publications and include delayed eruption of permanent dentition and mandibular retrognathism, absence of lower perm central incisor, two cases of only one maxillary central incisor, and taurodontism of the pulp chambers of primary molars.

Case Report:
10 year old male was dx with CHARGE at 13 wks. Pregnancy and birth non-remarkable with no family hx reported. Patient presents with choanal atresia, atrial septal defect requiring antibiotic prophylaxis, developmental delays, neurological abnormalities, dysmorphic facial features, and left optic nerve coloboma. Clinical dental exam revealed severe gingivitis, numerous carious primary and permanent teeth, high maxillary frenum attachment, and constriction of the palate. Radiographic findings include:
• Ectopic eruption #3
• Submergence #B
• Congenital absence #5
• Congenital absence #11
• Impaction/displacement #30 and 31 with associated radiolucency (lesion determined to be an odontogenic fibroma)

Authors suggested the impaction of #30 and ectopic eruption #3 may be related to the right side hypoplasia and facial asymmetry in this patient. No relationship between these two factors was offered. All treatment was completed under GA in the OR and included radiographs, EXT #31,K,S,T, routine restorative, and preventative procedures.

Summary of conclusions:
Previous dental findings with CHARGE association have included congenital absence of maxillary central incisors and delayed eruption of permanent teeth. In this case, a 10 year old boy exhibits delayed eruption, congenital absence of teeth, ectopic eruption of maxillary permanent first molars, submergence of primary molars, and an odontogenic fibroma associated with an impacted mandibular first permanent molar. A patient with CHARGE association will require a multi-specialty approach to treatment with regular clinical and radiographic monitoring.

Assessment of article:
Good article with much detailed information. The fact that CHARGE association can present with so many different anomalies must make diagnosis and treatment very challenging. It seems articles reporting dental anomalies of CHARGE patients are few and far between.

A review of liver transplantation for the dentist and guidelines for dental management

Resident: Roberts
Article: A review of liver transplantation for the dentist and guidelines for dental management
Author: Glassman, Paul. Et al
Journal: Special Care in Dentistry
Volume # 13 No. 2 pages 74 – 80
Year: 1993
The American Council of Transplantation states that a “successful transplant is one in which there is normal organ function one year after the transplant procedure.”
Chronic Liver Disease and Fulminant Hepatic Failure are the primary indications for a liver transplant. Imunosuppressive therapy is vital to postoperative success. However, a fine balance must be achieved in order to retain a healthy immune system and a successful graft. Infection is the most frequent cause of mortality and morbidity in liver transplant patients. Within the first 6 months most infections are related to the cytomegalovirus and after 6 months most infections are bacterial. Prior to transplant, dentist should be cautious about liver complications when regarding treatment. Definitive treatment should be performed prior to transplantation and the dentist should be aware of conditions such as PT, PTT. In the presence of ascites use prophylactic antibiotics for invasive procedures to avoid risk of infection. After transplantation, the dentist should consider steroid supplementation prior to stressful dental procedures such as extractions. Drugs such as acetaminophen, narcotics, lidocaine and other LA’s, barbiturates, and antibiotics should be used only after consultation with the patients physician and should be used conservatively. The main focus of the dentist at this point should be preventative and care should be taken so that infections do not occur and spread systemically.

Conclusion: Always know your med hx. BAZAam!

Oral health of children with congenital cardiac disease: a controlled study

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Boboia Date: 1/8/10
Article title: Oral health of children with congenital cardiac disease: a controlled study
Author(s): Hallet et all
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 14:4
Year: 1992
Introduction : The dental management of children with (Congential Cardiac Disease) CCD needs special considerations for the following reasons: predisposition to infective endocarditis for bacteremia induced dental procedures / poor oral health, reduced tolerance to stress induced by dental treatment, complications of CCD (hematologic, respiratory, and immunological).
Patients and Methods:
39 children with CCD and 33 healthy control siblings attending the dental clinic in Prince Charles’ Hospital (Brisbane); dental / medical histories, diet histories, oral exams were performed. Oral soft tissues were examined using a mouth mirror, perio tissues were not probed at first exam due to bacteremia. Teeth were examined for discolorations, developmental abnormalities, and caries. OH status was assessed using plaque index.
Results:
52% of children with CCD had enamel hypoplasia, compared with only 23% in the control group. CCD children also had significantly more teeth with untreated dental decay and more endodontically treated teeth. CCD children also had also had less then optimal professional and home dental care. Only 31% had professional advice regarding increased preventative dental health behavior, and only 15% used fluoride supplements. Significantly fewer CCD children had help with brushing (41%) compared with controls (70%).

Discussion:
Children with CCD suffer poorer oral health compared with control siblings. This was particularly evident in primary dentitions. Twice as many children with CCD had developmental defects and suffered from a higher prevalence of mesiocclusion and crowding, compared with unaffected children.

Conclusions:
Children with CCD should be targeted for vigorous preventive dental care

Oral health of children with congenital cardiac disease: a controlled study

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Boboia Date: 1/8/10
Article title: Oral health of children with congenital cardiac disease: a controlled study
Author(s): Hallet et all
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 14:4
Year: 1992
Introduction : The dental management of children with (Congential Cardiac Disease) CCD needs special considerations for the following reasons: predisposition to infective endocarditis for bacteremia induced dental procedures / poor oral health, reduced tolerance to stress induced by dental treatment, complications of CCD (hematologic, respiratory, and immunological).
Patients and Methods:
39 children with CCD and 33 healthy control siblings attending the dental clinic in Prince Charles’ Hospital (Brisbane); dental / medical histories, diet histories, oral exams were performed. Oral soft tissues were examined using a mouth mirror, perio tissues were not probed at first exam due to bacteremia. Teeth were examined for discolorations, developmental abnormalities, and caries. OH status was assessed using plaque index.
Results:
52% of children with CCD had enamel hypoplasia, compared with only 23% in the control group. CCD children also had significantly more teeth with untreated dental decay and more endodontically treated teeth. CCD children also had also had less then optimal professional and home dental care. Only 31% had professional advice regarding increased preventative dental health behavior, and only 15% used fluoride supplements. Significantly fewer CCD children had help with brushing (41%) compared with controls (70%).

Discussion:
Children with CCD suffer poorer oral health compared with control siblings. This was particularly evident in primary dentitions. Twice as many children with CCD had developmental defects and suffered from a higher prevalence of mesiocclusion and crowding, compared with unaffected children.

Conclusions:
Children with CCD should be targeted for vigorous preventive dental care

Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome 1/8/10

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

Article title: Dental Trauma After Cardiac Syncope in a Patient with Long QT Syndrome
Author(s): Karp, Jeffrey DMD. Gabriela Ganoza, DDS.
Journal: Pediatric Dentistry
Year, Volume (number), Page #’s: 2006. 28:6. 547-551
Major topic: How to approach a child with LQTS for dental TX
Minor topic(s): Use of a multidisciplinary approach
Main Purpose: Highlight the potentially malignant course of symptomatic LQTS and emphasize the importance of warning signs and multidisp. Medical management of children with LQTS
Overview of method of research: Review of syndrome, case report

Findings: Syncope occurs in roughly 1 out of every 800 pediatric patients seeking medical attention. Syncope is defined as a loss of consciousness related to decreased cerebral perfusion and can be mediated by several mechanisms. Neurocardiogenic, AKA vasovagal syncope, is the most common and occurs during periods of emotional stress. The prodromal symptoms are1. Lightheadedness2. Dizziness3. Nausea4. Pallor5. diaphoresis6. Visual changesVasovagal syncope is normally benign. The other type of syncope is cardiac syncope, which is a result of cardiac abnormalities in which obstruction to blood flow, myocardial dysfunction, and arrhythmias occur. These conditions can be due to genetic mutations, following a familial distribution. Long QT syndrome is a cardiac electrophysiological abnormality where the QT interval indicative of ventricular depolarization is prolonged on an ECG. LQTS can occur through either autosomal dominant of de novo mutation. It occurs in 1 out of every 5,000-10,000 individuals in the US(wide range???). The prolonged ventricular repolarization can lead to complex reentry circuits within the heart, loss of cardiac rhythm, and V-Tac, known as torsades de pointes(TdP). Tdp can be self-limiting; it can persist, or can cause V-Fib. All of these disarythmias compromise oxygen supply to the brain and other organs, leading to syncope, seizures, and death…, which stinks. Symptoms of LQTS include1. Unexplained syncope2. syncope during exercise in kids3. familial history of unexplained syncope4. seizures5. Sudden death in people <406. Congenital deafness7. QT interval longer than 440ms in males, 450 in females.There are four main treatment options for people diagnosed with LQTS.1. Beta blocker2. pacemakers3. implantable defibs. ICD4. left cardiac sympathetic denervation(LCSD)Success of treatment depends largely on the underlying genetic mutation. The article reviews a case of a 7 year old girl with a medical history of Pierre Robin Syndrome(PRS), ADHD, LQTS, and an implanted cardioverter defibrillator. The child was on 81mg of aspirin, 25mg of atenolol, and 10mg of atomoxetine. The child suffered avulsion of 8 and 9, and lateral luxation of 7. Apart form the initial exam, further dental TX was denied by the ED trauma team because the child developed a TdP rhythm. The child was later admitted. After multiple failed attempts due to cardiac complications, the dental team was finally allowed to render TX on the 5th day of the child’s hospital stay with the use of IV sedation. #7 had +2 mobility, and was deemed to be an aspiration and infection risk, and thus was planned for extraction. Due to the child’s medical status and complication associated with her conditions(glossoptosis, micrognathia), TX in the OR was decided on. The child received consults from her cardiologist, an anesthesiologist, and their PCP before TX under GA. Once in the OR, #7 was extracted and an impression was taken. There were no complications, and the child was discharged later that day.

Key points/Summary: The basic purpose of the case report is to raise awareness on the early signs and symptoms of LQTS and how it should be dealt with in the dental setting. A comprehensive medical history is paramount. A multidisciplinary approach is best. Consults are needed with the child’s cardiologist, neurologist, and PCP. With LQTS, use of choral hydrate and epinephrine are contraindicated because they prolong QT. Treatment under GA is the best option for care due to the necessity of monitoring the child’s cardiac condition by a cardiologist, even for routine dental treatment. In terms of treatment, a definitive restoration should be placed when possible, minimizing the risk of recurrent decay, failed pulpal therapies, and subsequent emergent care. With regards to trauma, the more appropriate treatment is extraction rather than endo. And some form of complex restorative care (in SOME instances). Replacement of lost teeth is assessed on a case by case basis, taking into account the child’s risk factors, health status, etc.
Assessment of Article: Good article. Concise, to the point on how to best treat kids with LQTS. The main points to take away are that a multidisciplinary approach is the only way to properly and safely treat these kids, and that they should be seen in the OR. Werd. Holla back youngin'.

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Tetralogy of Fallot: Characteristics, dental implications and case study

Department of Pediatric Dentistry

Lutheran Medical Center

Date: 01/08/2010

Article title: Tetralogy of Fallot: Characteristics, dental implications and case study

Author(s): Roy A. Rockman, DDS

Journal: Journal of Dentistry for Children

Volume (number): page 147

Month, Year: March-April 1989

Major topic: Tetralogy of Fallot

Minor topics:

Type of Article: Informative and Case Study

Main Purpose: Familiarize the reader with this case entity and how it relates to dental treatment

Overview of method of research: Review of current treatment modalities and case review

Findings: Tetralogy of Fallot can cause Cyanosis, especially when children are under stress, which can lead to loss of consciousness, temporary paralysis, or even death. Bacterial endocarditis and brain abscesses secondary to dental treatment are also concerns.

Follow prophylactic guidelines and for acute hypoxic spells treat with O2 administration, place child in knee-to-chest position, administer morphine sulfate and/or propranolol. General anesthesia may be required as a therapeutic modality.

Key points/Summary :

Frequency and etiology

• 10% of all congenital heart disease, most common cardiac malformation resulting in cyanosis after one year of age.

Clinical features

• Children are prone to hypoxic or blue spells. Marked by anxiety and a sudden increase in cyanosis.
• 
  
• Child can become unconscious, experience paralysis, have convulsions or even die.
• 
  
• Infants like to lie on one side in a fetal position, oder kids don’t like to stand for long periods and often squat after exertion.
• 
  
• Clubbing of fingers and toes is common
• 
  
• Polycythemia may result from low arterial O₂ concentrations. Hemorrhage can result.
• 
  
• Cerebral abscess is common: 20% incidence in children over 2.

Medical Management

• Corrective surgery is performed. Often it is palliative until age 5 when the pulmonary arteries are large enough for definitive corrective surgery.
• Pediatric illness that could cause dehydration or thrombic complications are treated aggressively.

Case Report: 3.5 year old boy presents to dental clinic in Kansas with severe tetralogy of Fallot. His only medication is Digoxin. His medical condition was considered stable at that time. Hx. of Blalock-Taussig shunt was performed as palliative surgical intervention.

Dentally, the child needed full mouth rehabilitation, had poor OH and cyanotic gingiva. After parent and pediatrician consultations General Anesthesia was chosen for modality of treatment. 2 years later, the child was treated in the OR.

Primary concerns were reduction of extreme agitation, avoidance of hypoxia and maintenance of normal blood volume.

IV antibiotic prophylaxis was used.

The dentist believes that pulpotomy and pulpectomy are contraindicated for patients with cardiac complications, so many primary teeth were removed and space maintenance was done.

Assessment of article:

The article shows its age by the extreme concern over bacterial endocarditis. Also it talks about a case of cerebral abscess in a child, who had a pulpotomy performed 3 years prior and it suggests that the pulpotomy was the source of the bacteria causing the cerebral abscess. It was so speculative, it seemed like a stretch to me.

Otherwise informative and useful to know for these patients.

Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation

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

Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation

Background

- The most frequently documented source of sepsis in the immunosuppressed cancer patient is the mouth.

- Early and radical dental intervention, including aggressive oral hygiene measures, reduces the risk for oral and associated systemic complications.

Recommendations

- All patients with cancer should have an oral examination before initiation of the oncology therapy.

- Existing or potential sources of infection need to be identified and treated.

- Parents and other caregivers need to be educated about the importance of optimal hygiene and oral care during and after treatment.

- Patients who receive radiation therapy to the masticatory muscles may develop trismus. Daily stretching oral exercises should start before radiation and continue throughout treatment.

- Hematological considerations:

o Absolute neutrophil count (ANC) - <1,000/mm3 defer elective dental care. Emergency dental care should be discussed with the patient’s physician and may require hospitalization.

o Platelet count – 40,000-75,000/mm3 may need to consider platelet transfusion. <40,000/mm3 defer elective dental care.

- Ideally, all dental treatment should be accomplished before cancer therapy is initiated. If dental work is needed once cancer therapy is started, treat between chemotherapy cycles - the patient’s hematological status is usually the most stable in the few days between treatment cycles.

- Dental care should be aimed at preventing infection and may need to be more aggressive for these patients. Primary teeth with pulpal involvement should be extracted, rather than treated with a pulpotomy. Permanent teeth needing endo should only be saved if the RCT can be performed in a single visit; otherwise, extract. Orthodontic appliances may need to be removed if OH is poor or if the cancer treatment protocol is putting the patient at risk for developing mucositis. There are no clear recommendations for the use of prophylactic antibiotics for extractions. If the patient will or has received radiation to the face, caution should be taken due to the risk of osteoradionecrosis.

- During cancer treatment, if moderate to severe mucositis develops, the patient may use a foam toothbrush soaked in aqueous chlorhexadine for brushing; the use of a regular toothbrush should be resumed as soon as the mucositis improves.

- Oral hygiene needs to be impeccable during cancer treatment. Xerostomia may develop; fluoride rinses and gels are highly recommended.

- Patients who have experienced chronic or severe mucositis should be watched closely for malignant transformation of their oral mucosa.

- Orthodontic care may start or resume after all treatment is complete and after at least a 2-year disease-free survival.

- If a child is planned for hematopoietic cell transplantation (HCT), all dental treatment must be completed before the transplant.

- There will be prolonged immunosuppression following the transplant; elective dentistry will need to be postponed until immunological recovery has occurred.

Guidelines on Record Keeping and Informed Consent

Guideline on Record Keeping and Informed Consent.

Kris Hendricks, Lit Review 12/18/09

Records

Just copy the appendixes and use them. See, how easy was that?

Purpose: assist practitioners in creating a comprehensive patient record, but this is not meant to be the “standard of care”

Each patient should have an individual record, most of this seems intuitive at this point so there isn’t much to say.

In order to not overlook important details in your records, use the appendixes included to make sure your records have all needed elements.

Everything that is done, every correspondence, every mediation used, basically everything must be recorded.

In depth medical and dental histories and risk assessments too.

Informed Consent

Process of informing pt or custodial parent/guardian with relevant info regarding dx and tx needs so an educated decision can be made.

The ADA code of ethics says: “the dentist must inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”

Every person has the legal right to determine what happens to his or her own body.

States differ on their interpretation and expectations of informed consent. \

As we know the accompanying person of a minor patient may or may not legally be able to give informed consent.

Some states require written consent before treating a patient, but even if not mandated, it’s a smart idea.

Some states will allow oral conversations documented in the medical record.

Consent form should include proposed therapy, risks, benefits and possible alternative therapy.

Forms should utilize simple words and phrases. The lay person --or in the case of some parents extra-lay person—should be able to understand the forms.

Courts have decided that the use of overly broad terms like “all treatment deemed necessary by the doctor” are too unspecific and do not constitute informed consent.

There are lists of essential elements in the handbook.

Forms need to be procedure specific, and you will need different forms for different procedures.

Additional consent for protective stabilization and sedation should be used separately.