Reactions of children to maxillary infiltration and mandibular block injections

Resident: Cho

Author(s): Ram D, Peretz B.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2001. 23. 343-346.

Major topic: Maxillary infiltration injection, Mandibular block injection

Minor topic: Facial Pain Scale

Type of Article: Scientific Article

Main Purpose: The purpose of this study was to assess children’s reactions to the administration of local anesthetic injection in the mandible and maxilla, and to study their sensation of pain after each type of injection.

Overview of method of research:

26 children between the ages of 4-6 years and 34 children between the ages of 7-10 years participated in the study. All patients were ASA I, no prior dental treatment, needed at least two clinical non-emergency sessions of operative procedures preceded by local anesthetic injection one in the mandible and the other in the maxilla. Based on the Frankl Scale, all children demonstrated positive or definitely positive behavior during pretreatment evaluation. Euphemisitic phrases such as “putting tooth to sleep” were used to describe the injection to all the children.

5% lignocaine on a cotton-wool roll was applied as a topical anesthetic prior to the injection. A short needle was used for both maxillary infiltration and mandibular block. Injection of the local anesthetic 2% lidocaine 1:100,000 was slow at an average of 1mL per minute. All injections were carried out by the same dentist.

Each patient was randomly assigned to receive either maxillary infiltration for the first visit and mandibular block for the second visit OR mandibular block for the first visit and maxillary infiltration for the second visit. During the injection, the modified Behavioral Pain Scale by Taddio et al was used to evaluate the children by observing: 1) facial display, 2) arm/leg movements, 3) torso movements, 4) crying. A trained dental assistant, who did not participate in the treatment, recorded the behavior.

Immediately after the injections, the children were asked to complete the Facial Pain Scale (FPS) for subjective evaluation of feeling after the injection. FPS is a set of nine cartoon faces with varying facial expressions ranging from a smile/laughter (value 9) to that of tears (value 1). The child was asked to select the face “which looks like how you feel deep down inside, not the face you show to the world.”

Findings:

No significant differences were found whether the maxillary infiltration or the mandibular block was given the first visit vs. second visit. No significant differences were found between boys and girls. The majority of the patients did not cry at all during the procedure.

Key points/Summary: Administration of local anesthetic in the maxillary teeth has been traditionally considered less painful than a mandibular bock for pediatric dental patients. This study showed that:

1. Mandibular block and maxillary infiltration are accepted similarly by children when first administered.
2. Children may feel inconvenience or pain and react by crying, yet may report a positive feeling in general.

Assessment of Article: Good article. However, it is not reflective of pediatric patients in general since they only surveyed patients that were positive and definitely positive patients.

The Incidence of Adverse Reactions Following 4% Septocain(Articaine) in Children

Resident: Roberts

Date: 1/12/2011

Article title: The Incidence of Adverse Reactions Following 4% Septocain(Articaine) in Children

Author: Adequmi. A, et al.

Journal: Pediatric Dentistry

Volume: 30 Number: 5

Year: 2008

Background: Articaine hydrochloride originated in Germany in 1976 and has been widely used in other European countries. It was approved in April 2000 for use in the United States under the name Septocaine. It belongs to the amide group of local anesthetics and is unique in that it contains a thiophene ring and an ester group. The thiopene ring increases the lipid solubility of the anesthetic, giving it a faster onset of action. The ester group enables the drugs biotransformation in the plasma and the liver. It has a fast onset of action, profound anesthesia, and low allergenicity. It works by blocking the sodium and potassium channels during the propagation of action potential. The elimination half-time of articaine is about 20 minutes.

Purpose: The purpose of the study was to report adverse events following its use in children.

Method: A prospective study was carried out on children attending a university based pediatric clinic. Data included demographics, medical history, amount and site of injection, and treatment complexity. Follow up interviews were done by phone and conducted with the parents at 3, 5, 24, 48 hour intervals. The primary objective was to determine if there was any prolonged anesthesia, soft tissue injury and or pain.

Results: Of 264 original patients recruited for the interview, only 204 were obtained. Numbness and paresthesia was reported 40% of the time at 3 hours and 11% at 5 hours. Soft tissue injury was reported 14% of the time at 3 hours and was found to highest under the age of 7. The lip was the ost commonly affected site for injury. 20% reported post procedural pain at 3 and 5 hour interviews.

Conclusions according to author: Since prolonged numbness appears to be the most frequent adverse event and occurred primarily in children younger than 7 years old, parents need to be informed and reassured accordingly.

Assessment: The article sites a number of studies with similar results and conclusions. It appears from its long track record of use in Europe and in the U.S. that it is very good products to use when dealing with kids. Providers however need to realize that this drug has the potential to diffuse more easily through soft tissue and bone than other local anesthetics and may give a more profound and long lasting effect as well. We should use this knowlegde when counseling with parents of our patients after operative procedures to ensure their best safety.

Central Hemangioma: An Overview and Case Report

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:Central Hemangioma: An Overview and Case Report
Author(s): Nikhil Marwah, MDS, Archana Agnihorti BDS, Samir Dutta, MDS
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2006. vol 28 No 5. 460-467
Major topic: Central Hemangiomas
Minor topic(s): Differential diagnosis, treatment options, Case report
Overview of method of research: Review/Case Report

Findings:
Hemangioma is a benign tumor characterized by proliferation of blood vessels. Presentation of a central hemangioma (CH) in the maxilla or mandible is rare. The literature differs on the origin of CH. Some believe it is a reaction from endothelial proliferation, while others contend it is a hamartoma resulting from proliferation of mesoderm that differentiates and becomes vascularized. CH also may be congential in origin. However it is agreed that it is benign. Some CH exhibit large size increases and can be locally destructive. CH occurs most commonly in the mandible (usually the body, sometimes the condyle) with a male:female ratio of 1:3 with peak incidence in the second decade of life. A CH may contain fibrous CT, osseous tissue, or cavernous blood vessels. The characteristic appearance of CH is a sunburst, or soap bubble pattern.
CH is a great mimicker of other conditions. CH may be in the differential diagnosis for:
1. Osteosarcoma
2. FD
3. Central giant cell granuloma
4. Ameloblastoma
5. Multiple myelome
6. Dentigerous cyst
7. Odontogenic cyst
8. Central ateriovenous fistula (clinically)
9. Aneurysms (clinically)
10. Shunts (clinically)

Clinical Findings
A CH may show little to no evidence of any intrabony lesion. Possible symptoms are pain including referred pain to the ear, TMJ, and condyle, swelling, or throbbing, and may be present from 1 week to 10 months. Referred pain to the ear, TMJ, and condyle is possible as well.
Dental findings may include
1.Occlusal derangement
2. Displaced teeth
3. Supraeruption
4. Premature exfoliation of primary teeth
5. Early eruption of teeth.

Radiographic Appearance
Usually presents as an area of altered radiodensity, usually osteolytic, occasionally w/ central radiopaque areas and a trabecular pattern. Trabeculae are arranged as spokes of a wheel, radiating from the center to the periphery. A soap bubble, sunburst or honeycomb pattern is possible as well. Nearly any combination of lesion size, shape, location or pattern can develop, with well defined, ill defined, and scalloped margins all being possible. Due to the ambiguity of the radiographic exam of a CH, diagnosis by radiographs alone is impossible.

Histology
This is the diagnostic test for a CH. It can either be capillary, cavernous, or mixed.

Diagnosis
A biopsy is 100% necessary for proper diagnosis. However due to the vascular nature of CH, uncontrollable bleeding must be considered. Angiography is a very useful diagnostic tool, as is aspiration.

Treatment
1. Radiotherapy(500-3300 R)-Used when the lesion is inaccessible to surgery
2. Injection of sclerosing agents (Boiling H20, Na morrhuate, Na tetradecly sulfate)-Very irritating, thrombogenic
3. Surgical removal-Risky, but still used the most frequently. Sometimes surgery and embolization (occlusion of vessels feeding the lesion) are used in conjunction. The biggest concern is hemorrhaging.

Case Report
8 yo Indian boy presented with a mandibular left side swelling that had been present for 10 months. The child’s primary molar had been ext’s before the start of the swelling. It started out small, then grew for the first 5 months. The child had minor ‘tooth’ pain. The swelling was confined to the left, lateral aspect of the mandible, it was hard, nonhyperthermic, and only sensitive to deep palpation. PA’s we non descript. A panorex showed coarse trabeculations and an increased radiodensity extending from the mand. lateral incisor to the 1st molar. The tooth buds of the canine and second premolar were affected. There was a definite honeycomb appearance. Lab reports were all normal. Fine needle aspiration was done to confirm the diagnosis. The child was admitted to the hospital, declared healthy, and prepped for surgery. A submand. Incision was made from the angle of the mandible to the symphyseal area. Enbloc resection of the lesion, including 1 cm of healthy bone was performed. A nickel titanium plate was placed over the defect. Further lab tests confirmed the lesion was a CH. 8 weeks post surgery the child was healing well, and the graft was being planned.

Key points/Summary:
Diagnosis cannot be made by clinical exam and/or radiographic exam alone. The three treatment options all have their pro’s and con’s. Many factors must be taken into account before deciding which treatment is best. CH must always be considered in the DD and proper precautions must be taken in establishing the final diagnosis before any tx is initiated.

Assessment of Article: Good, thorough review of CH and it’s implications. I thought the case report was ok. Would have liked to see more pictures and radiographs and the follow up of the boy. Overall a good review.

Removal of a Complex Odontoma within a Dentigerous Cyst

Resident: Swan

Article Title: Large Erupting Complex Odontoma in a Dentigerous Cyst Removed by a Piecemeal Resection

Authors: Biocic, et al.

Journal: Pediatric Dentistry 32:3, June 2010

Article Type: Case Report

Main Topic: Odontomas

Odontomas in general:

These lesions are the most common Odontogenic Tumor in European, North American, and South American populations. Compound odontomas are more common than complex. Complex typically occur in the posterior mandible, while compound usually present in the antetior maxilla. They typically cause no clinical symptoms and are found during routine radiographic examination. They are often associated with failed eruption of permanent and, rarely, primary teeth. Radiographically, odontomas present as well-defined radiopacities within the bone with a peripheral radiolucent zone representing the follicle. Occasionally, they are associated with a dentigerous cyst. This is a case report of such a scenario.

Case Report:

A 10 year old otherwise healthy patient presented to the authors' clinic in Croatia with painful swelling of the right mandible and cheek that had lasted one week. The mother reported previous swellings of a similar nature, that all spontaneously went away. On extraoral examination, the patient presented with facial asymmetry and a soft painful swelling at the angle of the mandible, extending up to the right cheek. Lymphadenopathy was also observed in the area. Intraorally there was an oral mucosal defect distal to #30 resembling exposed alveolar bone or tooth remnants. The buccal and lingual cortical plates were distended, and the pano showed a large (5X3 cm), nonuniform, radiopaque mass surrounded by an unevenly wide radiolucent zone surrounding the entire mass. In the lower distal portion of the mass, a tooth bud of a developing lower second molar was observed.

And here it is:

Laboratory findings were within normal limits, however, alkaline phosphatase was elevated. A biopsy performed under general anesthesia revealed a complex odontoma and an inflamed dentigerous cyst.

Definitive surgical treatment (also performed under general anesthesia):

The lesion was removed via piecemeal resection. The lower part of the tumor was removed together with the cyst. The buccal cortex and inferior mandular border were preserved, but the mass destroyed the lingual cortex. A suction drain was placed and secured in the lower vestibule and the flap was replaced. When the drain was empty 3 days postoperatively, it was removed. Recovery was uneventful and the patient showed no signs of recurrence 2 years later.

Discussion:

This is a case report of a situation that occurs very infrequently: A complex odontoma associated with a dentigerous cyst, with the odontoma erupting into the oral cavity. The surgeons had 4 options for its removal:

1. segmental resection of the mandible with subsequent reconstruction

2. sagital split osteotomy

3. two stage removal

4. separation with a bur, with subsequent piecemeal resection of the odontoma and cyst

The authors chose option 4 and obtained a great result.

Much love from Utah.

Odontogenic Myxoma in the Pediatric Patient: A Literature Review and Case Report

Resident: Cho

Author(s): Harokopakis-Hajishengallis E, et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2007. 29. 409-414.

Major topic: Odontogenic Myxoma

Type of Article: Case Report

Key points/Summary:

Myxoma: benign soft tissue or bone neoplasm that may appear anywhere in the body.

Most central myxomas occur in the jaws where they are called odontogenic myxomas (OM) because of their presumably odontogenic origin although their histologic origin is still controversial.

OM is a rare neoplasm with an annual incidence of 0.07 per million. Among other odontogenic tumors, however, OM is the second most common following ameloblastoma. OM should be considered in the radiographic differential dx. of dentigerous cyst, odontogenic keratocyst, ameloblastoma, central giant cell granuloma, central hemangioma, traumatic bone cyst, aneurysmal bone cysts, or fibrous dysplasia. OM is most commonly seen between ages of 10 and 40 years of age (young adult).

OM occurs in both the maxilla and mandible and is usually unilateral – rarely crosses the midline. Posterior region of the jaw is the most common site. 5% of the cases is associated with an unerupted tooth.

OM is a locally invasive lesion that grows slowly and generally without significant symptoms. On average, there is a delay of 1 to 5 years form the lesion’s onset to the first sign, which is usually a slow growing facial or intraoral swelling that causes the patient to seek medical help. Involved teeth may become mobile and malpositioned, but they remain viable. Symptoms such as nasal obstruction, diplopia, pain, or paresthesia may develop upon bony perforation and invasion in the maxillary sinus, palate, orbit, and nasal cavity.

Radiographically, OM commonly presents as unilocular or multilocular, well-defined radiolocuency with “soap-bubble” or “tennis racquet” appearance. The “tennis racquet” appearance is almost pathognomonic of OM but only is seen in 1/3 of the cases. OM is associated with tooth displacement in 26% of the cases and/or root resorption in up to 50% of the cases.

Upon gross examination, OM appears as a white or yellow, gelatinous lobulated mass. Histologically, it is composed of spindle-shaped and stellate cells interspersed in the loose mucoid background. Odontogenic epithelium may or may not be found.

The generally accepted treatment of OM includes resection of the tumor with a greater than 1.5cm margin of the surrounding tissue to prevent recurrence. The overall prognosis for OM is generally good – average recurrence rate is 25%. Recurrence usually occurs during the first 2 years after treatment. Malignant transformation is extremely rare and metastasis has not been reported.

CASE REPORT

Healthy 6-year, 11-month female with unremarkable medical history, no dental caries, normal complement of teeth for her age presents on radiographic exam with bifurcation radiolucency and root resorption around #J, poorly defined radiolucency in the furcation of #J, unerupted #13 displaced superiorly.

#J was extracted and incisional biopsy performed. Microscopic exam of excised mucoid soft tissue provided histopathologic diagnosis of odontogenic myxoma. It showed stellate-shaped fibroblastic cells interspersed in matrix blue ground substance.

Upon CT, the lesion presented as a single unilocular radiolucency with well-defined scalloped borders located superior to extraction socket of #J. Adjacent to unerupted #13, it had caused buccal expansion, thinning, and convexity of the inferior floor of the maxillary sinus. The mass was surgically excised in the OR. The buccal cortex surrounding the lesion was removed and the tumor was enucleated without difficulty. #14, unerupted #12, unerupted #13, and #I were all extracted due to being inside the tumor bed or close to the tumor bed. 9 months following the lesion’s excision, the patient has shown no evidence of recurrence.

Assessment of Article: Excellent article. Learned a lot and thought that it gave a very thorough description of odontogenic myxomas.

Benign Teratoma of the Tongue in a Neonate: A Case Report and Review of the Literature

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Benign Teratoma of the Tongue in a Neonate: A Case Report and Review of the Literature

Author(s): Shetty et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2010. 32:3. 245-249.

Major topic: Benign Teratoma of Tongue

Overview of method of research: Case Report

Background:
Teratomas are neoplasms with the ability to grow continuously and are the most common extragonadal germ cell tumors of childhood. The cause of these neoplasms are unknown. Teratomas of the tongue are very rare and may develop from misplaced cells from the tuberculum impar.

Case Report:
A 6-week-old male presented in India for evaluation of a congenital lesion that had remained unchanged since birth. He was experiencing difficulty swallowing and breast-feeding, but no breathing problems. Clinical exam revealed a 2x1.5x1.5 cm pedunculated mass with smooth surface and normal coloring on the anterior 2/3 of the dorsum of the tongue. The patient experienced severe ankyloglossia and also polydactyly in all 4 limbs.
A team of oral and maxillofacial surgeons and pediatric dentists excised the mass under nasotracheal intubation with a circumferential incision including a few millimeters of healthy tissue. The lesion was cauterized and primary closure was obtained and a frenectomy was performed to correct the ankyloglossia. Histopathological exam revealed fibrous connective tissue, adipose tissue, mixed salivary glands, sebaceous glands, striated muscle, chondroid tissue and blood vessels and there was no evidence of malignancy.

Discussion:
Teratomas are classified into 4 different types:
1. dermoid- epidermal and mesodermal elements, most common
2. teratoid- ectodermal, mesodermal and endodermal, but poorly differentiated
3. true teratoma- 3 germ layers and differentiated
4. epignathus- highly differentiated into recognizable organs/limbs, high mortality rate
There have only been 20 documented cases of tongue teratoma since 1966. 75% experienced difficulty eating, but only 35% had problems breathing. Although the majority of cases are benign, 20% possessed histological evidence of malignancy.
Differential diagnosis: lymphangioma, hemangioma, granular cell myoblastoma, gastric mucosal cyst, lingual thyroid, thyroglossal duct cyst, ectodermal inclusion body, heterotropic gastric mucosal mucosal cyst, congenital rhabdomyosarcoma, encephalocele, glioma and neurofibromatosis.
Surgical excision is the treatment of choice and recurrence is rare.

Assessment of Article:
A well written article and good overview of teratomas, their clinical presentation, differential diagnosis and treatment.

01/05/2011 Molar Incisor Hypomineralization: Review and Recommendations for Clinical Management

Resident: J. Hencler
Date: 01/05/2011

Article title: Molar Incisor Hypomineralization: Review and Recommendations for Clinical Management

Author: Williams et al.
Journal: Pediatric Dentistry-28:3 2006

Major topic: Molar incisor hypomineralization (MIH)
Type of Article: Lierature Review

Main Purpose:
Describe the diagnosis, prevalence, putative etiological factors, and features of hypomineralized enamel in MIH and present a sequential approach to management.

Background:
MIH was introduced in 2001 to describe the clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFMs) that are frequently associated w/ affected incisors. MIH is attributed to disrupted ameloblastic function during the transitional and maturational stages of amelogenesis. MIH’s clinical management is challenging due to the sensitivity and rapid development of caries in affected PFMs, the limited cooperation of a young child, difficulty in achieving anesthesia, and the repeated marginal breakdown of restorations.

MIH Diagnosis:
After a thorough prophy, the 4 PFMs and 8 erupted permanent incisors are examined wet for demarcated opacities, post eruption breakdown (PEB), and atypical restorations. Opacities are usually limited to the incisal or cuspal 1/3 of the crown, rarely involving the cervical 1/3. Restorations may not conform to typical caries pattern and frequently involve the cuspal or incisal 1/3 of the crown. Teeth with developmental defects of enamel may present similarly regardless of etiology and confused with MIH. For example, Enamel hypoplasia (EH) is a quantitative defect associated with a reduced localized thickness of enamel, following disruption of the secretory phase of amelogenesis. MIH and EH can be difficult to differentiate when affected molars have PEB due to caries or masticatory trauma.

Hypomineralized Enamel Characteristics:
Hypomineralization is thought to follow deposition of the full thickness of enamel matrix. The transitional ameloblast is considered most vulnerable and when these cells do not undergo complete maturation, full-thickness hypomineralization occurs. Hypomineralization is thought to be due to disturbed resorptive potential of ameloblasts and proteolytic enzyme inhibition, leading to protein retention and interference w/ crystal growth and enamel maturation. Also, conditions affecting matrix pH during enamel maturation and impaired calcium metabolism may predispose MIH.

Factors Associated With MIH:
Putative factors associated w/ disrupted amelogenesis of PFMs include systemic conditions and environmental insults influencing natal and early development. Although a number of etiological factors may contribute to MIH, the threshold needed to cause enamel defects at sensitive stages of amelogenesis is unknown and 2 or more concurrent conditions may act synergistically to produce a defect. Conditions common in the first 3 years, such as upper respiratory diseases, asthma, otitis media, tonsillitis, chicken pox, measles, and rubella, appear to be associated w/ MIH. Antibiotic usage has also been implicated but due to the concurrence of the disease and antibiotic therapy, it is difficult to determine whether MIH is associated with the disease, the antibiotic, or both. Systemic conditions implicated to date include nutritional deficiencies, brain injury and neurological defects, cystic fibrosis, syndromes of epilepsy and dementia (Kohlschutter-Tonz syndrome), nephritic syndrome, atopia, lead poisoning, repaired cleft lip and palate, radiation treatment, rubella embryopathy, epidermolysis bullosa, ophthalmic conditions, celiac disease, and GI disorders.

Prevalence of MIH:
Prevalence data is limited due to several diagnostic classifications but range from 4-25%

Risk Identification, Remineralization, and Preventaive Management:
Children at risk for MIH should be identified prior to PFM eruption if possible based on history of etiological factors in the first 3 years and careful radiographic exam of unerupted first molar crowns. Thorough OH should be instituted including desensitizing toothpaste. Remineralization therapy should commence as soon as the defective surface is accessible, aimimg to produce a hypermineralized surface layer and to desensitize the tooth. This can be accomplished with casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) oral care products that enhance remineralization by creating a state of supersturation followed by deposition of calcium and phosphate ions at the enamel surface. OH strategies for sensitive, poorly mineralized affected molar should include brushing affected molars with fluoridated desensitizing toothpaste w/ a soft toothbrush, apply a CPP-ACP topical cream, and apply a low concentration fluoride treatment gel regularly. As remineralization and desensitization of the affect molars occurs, regular OH strategies can be instituted.

Restoring Hypomineralized First Permanent Molars:
Restoring affected PFMs is frequently complicated by difficulties in achieving anesthesia, managing the child’s behavior, determining how much affected enamel to remove, and selecting a suitable restorative material. The choice of material will depend on the defect severity and the age of the child. Restorative options include glass ionomer cements (GIC), resin-modified glass ionomer cements (RMGIC), polyacid modified resin composites (PMRC), resin composites (RC), amalgam, stainless steel crowns (SSCs), and indirect adhesive or cast onlays or crowns. Amalgam is the least durable due to poor retention in shallow cavity preps and inability to protect remaining tooth structure. Adhesive materials are usually chosen due to the atypical cavity outlines following removal of affected enamel. Removal of all defective enamel is recommended when bonding resin composite to hypomineralized PFMs due to the poor bond strength of resin adhesives to hypomineralized enamel.

Restoring Hypomineralized Permanenet Incisors:
Hypomineralized incisors commonly seen in MIH may present with esthetic concerns that can complicate treatment. A conservative approach includes etching lesion, bleach w/ 5% NaOCl, and re-etch the enamel prior to placing a sealant over the surface to occlude porosities and prevent re-staining. Little improvement was reported with acid/pumice micro-abrasion. Esthetic improvement was achieved when enamel reduction was combined with opaque resins then direct RC veneering.

Adhesion To Hypomineralized Enamel:
The limited literature on adhesion of dental materials to hypomineralized enamel has focused on case reports of Amelogenesis Imperfecta (AI). Bond strengths of RC to hypomineralized enamel of PFMs affected with MIH are significantly less than bond strengths to normal enamel for both single-bottle total etch and self-etching primer adhesives. After removing all discolored hypomineralized enamel, cavity margins should be placed on sound enamel and RC should be bonded w/ a self-etching primer adhesive.

Full Coronal Coverage Restorations:
When PFMs have moderate to severe PEB, SSCs are the treatment of choice. SSCs prevent further tooth deterioration, control tooth sensitivity, establish correct interproximal contacts and proper occlusal relationships, are not as technique sensitive or costly as cast restorations, and require little time to prepare and insert. If not adapted properly, however, SSCs may produce an open bite or gingivitis.

Extraction Of Severly Hypomineralized First Permanent Molars:
When PFMs are severely hypomineralized, restorations may be impossible and extraction must be considered. In such cases, early orthodontic assessment is recommended.

Summary of conclusions:
The prevalence of MIH appears to be increasing and managing affected children is now a common problem for pediatric dentists. Although the etiology is unclear and may be multifactorial, children born preterm and those w/ poor general health or systemic conditions in their first 3 years may develop MIH. The early identification of such children will allow monitoring of their PFMs so that remineralization and preventative measure can be instituted as soon as the affected surfaces are accessible.

Assessment of article:
Good review of MIH. More research needed. Because the prevalence of MIH is increasing it would helpful to know more info about the etiology and if in fact the condition is multifactorial.

Peripheral Ossifying Fibroma - A Clinical Evaluation of 134 Pediatric Cases.

Resident: Adam J. Bottrill
Date: 22DEC10
Region: Providence
Article title: Peripheral Ossifying Fibroma - A Clinical Evaluation of 134 Pediatric Cases.
Author(s): Elvira S. Cuisia Zenaida
Journal: Pediatric Dentistry
Page #s: 245-248
Vol:No Date: 23:3 2001
Major topic: Peripheral ossifying fibroma
Minor topic(s): NA
Type of Article: Clinical Evaluation

Main Purpose: This study, the first devoted to children, investigated the clinical features of a large number of POF's and compared the findings to cases reported in the English language literature.




Key points in the article discussion:

I. General:

A. Solitary gingival enlargements common in children. Usually due to irritation.
B. Peripheral Ossifying Fibroma:
1. Gingival nodule, cellular fibroblastic connective-tissue stroma with dispersed calcified foci.
2. Localized, exophytic lesion with sessile or peduculated base.
3. Most studies on POF's concentrate on the entire category of "fibroma's". Also, there are NO studies on POF's in the pediatric population.
4. Reactive lesions like POF do have pediatric significance that require early recognition and treatment by a dentist.
5. Definative etiology unknown
6. DD: Pyogenic Granuloma, Fibroma, Peripheral giant cell granuloma, irritation fibroma, papilloma, peripheral odontogenic fibroma

II. Methods:

A. Clinical and historical information of 134 surgically-removed POF's in patients age 1-19.
B. Clinical Manifestations, histogenesis, treatment rationale, biological behavior were emphasized.
C. 657 POF's in the 43362 biopsies during the study period. Only 134 (20%) were pediatric patients.

III. Results

A. Females (60%)
B. Maxillary Gingiva (60%)
C. Incisor/cuspid region
D. Average age 14yo (6mo to 19yo)
E. 71% of cases were found in black pts. (MAY indicated increased incidence)
F. Color: pink to reddish
G. 63% of lesions were ulcerated.
H. Size: 0.3 - 3.0 cm
I. Only 2 (1%) associated with primary teeth.
J. Clinician RARELY included POF in DD.
K. Recurrence rate after excision 8% (vary from 7-46% depending on the study)
1. This 8% may be inaccurate due to the nature of this study. There was no attempt to determine the recurrence rate of patients who did not follow up.

VI. Conclusions

A. Must consider taking radiographs, even for soft tissue lesions such as POF in order to determine the extent of the lesion and eliminate the DD.
B. POF is a well-defined pathologic entity among reactive gingival lesions.
C. Peak incidence is in the 2nd decade. Incidence of POF in 1st decade is very uncommon.
D. POF most common in female.
E. POF found mostly in maxillary incisor region.
F. POF arising from PDL of primary tooth uncommon.
G. Proper treatment protocol is warranted with close follow-up.

Assessment of article: Informative. Large "n". The author attempts to tag this study as somewhat "ground-breaking" by mentioning it's the first PEDIATRIC study of it's kind. I suppose it's interesting, but I don't see it changing the way I treat patients. The conclusions were appropriate. Medium Likey.

Dentigerous Cysts in Primary Dentition: Report of 2 cases

Dentigerous Cysts in Primary Dentition: Report of 2 cases

Resident: Tyler Roberts
Author: Delbem et al
Journal: Pediatric Dentistry
Volume # 28:3, pages 269-271
Year: 2006
Major topic: Dentigerous cyst in children/adolescents
Type of article: case review
Kep pts/findings:
Dentigerous cyst are benign odontogenic cysts associated with the crowns of unerupted permanent teeth. They are usually single in occurrence and located in the mandible. They are the second most common type of odontogenic cyst, accounting for 49% of all cystic lesions. They are most common in male patients and frequently occur during the second or third decade of life. These lesions are usually asymptomatic and discovered at the time of routine radiographic examination. If the cyst is greater than 2cm in diameter swelling, mild sensitivity, tooth mobility and displacement may be observed. Radiographically these lesions are symmetric, well-defined, unilocular surrounding the crown of the unerupted tooth. Possible complications include: permanent bone deformation or fracture, expansive bone destruction, loss of permanent teeth, development of squamous cell carcinoma

Case 1
A 10 year old presented with swelling on the left side of his jaw. An intraoral examination revealed bulging along the cortical bone that extended from his mandibular left first bicuspid to the distal of the permanent mandibular left first molar and a radiographic lesion that appeared unilocular, radiolucent and was associated with the dental crown of the bud of the mandibular left second molar. A differential diagnosis suggested a dentigerous cyst. Marsupialization was chosen as treatment. The primary mandibular left second molar was extracted, the lesion was decompressed and a space maintenance appliance was inserted. The parents were told to irrigate the lesion with listerine solution and clean the appliance daily. A histopathologic examination revealed that the lesion was indeed a dentigerous cyst.

Case 2
An 8 year old boy, was found to have a volumetric increase of the lingual cortical plate in the region of the primary mandibular right lataeral incisor which showed prolonged retention. Radiographically a well-defined, unilocular, radiolucent lesion was present surrounding the bud of the permanant mandibular right lateral incisor. The lesion appeared to be causing root resportion of the primary lateral incisor and canine. The working diagnosis was a dentigerous cyst. Treatment included extraction of the primary mandibular right lateral incisor and primary canine as well as total enucleation of the cyst due to the small size. Stitches were placed and removed seven days later and seven months later eruptive movements of the permanent right lateral incisor was present along with new bone neoformation was visible in the area.

Summary of conclusions/Assessment: Dentigerous cysts are benign and asymptomatic. Because they are common among cyst they should not be overlooked at the time of routine radiographic examination. Small cyst are most likely to undergo complete enucleation while larger cyst may require decompression for healing to take place.

Juvenile Oral Lichen Planus: A Report of 2 Cases

Meghan Sullivan Walsh January 2, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Juvenile Oral Lichen Planus: A Report of 2 Cases

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Juvenile Oral Lichen Planus: A Report of 2 Cases

Authors: Victoria L. Woo, DDS; Akanksha Manchanda-Gera, BA; Derek S. Park, BA, MA; Angela J. Yoon, DDS, MPH, MA; David J. Zegarelli, DDS

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 29, NO 6, November/December 2007, pages 525-529.

Major Topic: Juvenile Lichen Planus

Overview of Method of Research: Lichen Planus or LP is an inflammatory disease which can present itself in a variety of formats and sites. Cutaneous LP is characterized as purple pruritic, polygonal papules with reticular striations found mostly on the extremities and lower back. Oral LP is divided into 6 subgroups; Papular, Reticular, Plaque-like, Ulcerative (erosive), Erythematous (atrophic) and Bullous. The two most common oral forms are Ulcerative and Reticular. Both forms present as bilateral, symmetric lesions with periods of quiescence and exacerbation. Of note is that LP is often found simultaneously with Lupus erythematosus, pemphigus, Sjogren’s syndrome, 10 autoimmune liver disease, rheumatoid arthritis and dermatomyositis. The purpose of this article was to report two children with documented cases of Juvenile Oral Lichen Planus and provide a literature review of this disease.

Findings: Two children presented to the Division of Oral Pathology, Columbia University College of Dental Medicine for evaluation of oral lesions. The first case was a 9 year old Caucasian female with bilateral tongue lesions which caused her discomfort with certain foods and liquids. Her medical history was negative. The lesions presented as ulcers on her right and left lateral ventral tongue surfaces with an adherent, white reticular and papular pattern. The histopathology report revealed lichenoid mucositis consistent with lichen planus. The patient was placed on beclomethasone dipropionate inhaler and dexamethosone elixir and advised to return every 6 months for future evaluation. Unfortunately this patient never returned for follow-up visits.

The second case was an 11 year old Caucasian female with bilateral, asymptomatic mucosal tongue lesions. The patient had a negative medical history but interestingly had received 3 hepatitis B vaccinations at 1 month, 2 months, and 6 months of age. The intra-oral examination showed classic white, lacy striations on the right and left posterior buccal mucosa. A biopsy confirmed lichen planus. Since the patient was asymptomatic no future treatment was given at this time. Follow-up of this patient in one year showed similar intra-oral lesions.

Key Points: Summary: Criteria for juvenile oral Lichen Planus include:

1: Patient is less than 20 years old

2: Clinical evidence of oral lichen planus

3: Oral biopsy confirmation of lichen planus, lichenoid lesion, or lichenoid mucositis

4: A clinical description of “reticular” or “reticulate,” “straie, or “straited,” and/or “lacy” oral lesions.

5: No evidence of mucosal contact with dental restorations, no exposure to medications known to induce oral lichenoid reactions and no history of graph verse host disease.

The literature review showed Juvenile OLP occurred more frequently in males, ages 11-15 with no ethnic predilection. The buccal mucosa was the most commonly affected site and most patients were affected by the reticular OLP. Important factors in the development of Juvenile OLP include previous Hep B vaccinations, liver disease and a genetic predisposition. Erosive OLP is extremely rare in the young population. Treatment of these patients is close monitoring of those asymptomatic and topical steroids for the symptomatic patients.

Assessment of the Article: Very well written article regarding Juvenile Oral Lichen Planus. Very thorough discussion of the disease, characteristics and treatment. Was surprised to hear about Juvenile OLP relationship with the Hepatitis B vaccination.