Resident: Swan
Article Title: Prevalence of 3-Rooted Primary Mandibular Second Molars among Chinese Patients
Author: Liu et al.
Journal: Pediatric Dentistry
Volume (Number): 32 (2)
Major Topic: Primary molar anatomy
Type of Article: Retrospective Study
Main Purpose: Determine the prevalence of 3-rooted primary mandibular second molars in vertical bitewing radiographs obtained from a group of Chinese patients
Overview of method of research: Vertical bitewing radiographs of 185 patients showing bilateral primary mandibular second molars were evaluated by two calibrated dentists, a pediatric dentist, and an endodontist. The presence of an extra root was determined by the crossing of radiolucent lines corresponding to the PDL space of the extra root superimposed on the molar’s pulp floor. Disagreements between examiners were resolved by consensus between 2 investigators.
Findings: An extra distal root in mandibular primary second molars was found in 18/185 (10%) of the patients examined, more specifically, in 23 of the 370 total teeth. Bilateral 3-rooted molars were found in 5 patients (2.7%). The occurrence of such molars did not differ significantly between males and females.
Key Points/Summary: Various studies have examined the prevalence of 3-rooted primary mandibular second molars among different populations. The prevalence found in this study (10%) is on the high end compared to other studies that have been done with larger populations. Other studies suggest that if the primary second molar has three roots, there is a high probability that the permanent first molar will also have one. This is based on theory more than science and more studies need to be done to substantiate it.
Assessment of Article: Decent study about a very specific population. Very subjective determination of root anomalies from radiographs. Hard to generalize these results. Here’s to the 2nd years not missing any board questions about Chinese mandibular second molars!
Tuesday, February 8, 2011
Monday, February 7, 2011
01/19/2011 Characterization of Primary Dental Pulp Cells In Vitro
Resident: J. Hencler
Date: 01/19/2011
Article title: Characterization of Primary Dental Pulp Cells In Vitro
Author(s): Coppe et al
Journal: Pediatric Dentistry V31/NO7 NOV/DEC09
Major topic: Potential of pulp stem cells
Type of Article: Scientific
Main Purpose:
Characterize dental pulp cells from human primary teeth and determine their ability to induce differentiation of oral epithelial cells
Overview of method of research:
Dental pulp cells were isolated from freshly extracted primary incisors, digested w/ collagenase/dipase and grown in medium w/ fetal bovine serum. Stem cell populations were identified by immunocytochemical staining for STRO-1 and CD146 and fluorescence activated cell sorting. To determine whether primary pulp cells can signal epithelium, the pulp cells were grown in coculture w/ human fetal oral epithelial cells (OECs). After 3 days, the cocultured cells were collected and analyzed for amelogenin expression by PCR and immunocytochemical staining.
Findings:
Immunofluorescence and fluorescence activated cell sorting of STRO-1 positive cells showed this stem cell population to be approximately 2% of the total population. Growth-arrested primary dental cells grown in coculture w/ OECs showed expression of amelogenin by immunocytochemistry and PCR. OECs were alone amelogenin immunonegative.
Key points in the article discussion:
The finding that human primary teeth contain multipotent stem cells has generated much interest in their potential use as a resource for stem cells to repair damaged tooth structures. Stem cells from human exfoliated deciduous teeth (SHEDs) were found to express STRO-1 and CD146, two early mesenchymal stem cell markers. The stem cell populations from primary teeth were found to have a higher proliferation rate than those from permanent teeth. Although primary human teeth contain stem cell populations, this is a minor component of the pulp cell population. Only 2% of the total primary cell population was found to be STRO-1 positive suggesting a relatively small population of stem cells within the primary tooth pulp. Although the authors report it was difficult to isolate pure stem cell populations from the primary tooth pulp, the upregulation of amelogenin in OECs when grown in coculture with the dental pulp cells from primary teeth (pDPCs), which includes a heterogeneous cell population of cells, suggests that these stem cells may not be necessary in large numbers to promote epithelial cell differentiation. The relatively few numbers of available pulp stem cells, the challenges in harvesting those stem cells, and the likely possibility that pulp stem cells are hematopoetically derived and could be much more easily obtained from blood or bone marrow, suggest that it is unlikely that dental pulp stem cells would be a primary source of cells for regeneration of other tissues. The ability of primary pulp stem cells to promote generation of tooth structures, including dentin and enamel, is more promising. Future research should include isolation and characterization of homogeneous populations of cells with in the dental pulp and their ability to regeneration tooth structures.
Summary of conclusions:
Mesenchymal stem cells can be isolated from primary tooth pulps. This heterogeneous population of cells can promote differentiation of fetal OECs into ameloblast lineage cells.
Assessment of article:
Good article with promising results. Good study design using many difficult microscopic and cell culturing techniques. The isolation of dental pulp cells from extracted primary teeth w/ moderate to severe caries may have had an effect on the numbers and viability of the stem cell line isolated in this study. Interesting stuff.
Date: 01/19/2011
Article title: Characterization of Primary Dental Pulp Cells In Vitro
Author(s): Coppe et al
Journal: Pediatric Dentistry V31/NO7 NOV/DEC09
Major topic: Potential of pulp stem cells
Type of Article: Scientific
Main Purpose:
Characterize dental pulp cells from human primary teeth and determine their ability to induce differentiation of oral epithelial cells
Overview of method of research:
Dental pulp cells were isolated from freshly extracted primary incisors, digested w/ collagenase/dipase and grown in medium w/ fetal bovine serum. Stem cell populations were identified by immunocytochemical staining for STRO-1 and CD146 and fluorescence activated cell sorting. To determine whether primary pulp cells can signal epithelium, the pulp cells were grown in coculture w/ human fetal oral epithelial cells (OECs). After 3 days, the cocultured cells were collected and analyzed for amelogenin expression by PCR and immunocytochemical staining.
Findings:
Immunofluorescence and fluorescence activated cell sorting of STRO-1 positive cells showed this stem cell population to be approximately 2% of the total population. Growth-arrested primary dental cells grown in coculture w/ OECs showed expression of amelogenin by immunocytochemistry and PCR. OECs were alone amelogenin immunonegative.
Key points in the article discussion:
The finding that human primary teeth contain multipotent stem cells has generated much interest in their potential use as a resource for stem cells to repair damaged tooth structures. Stem cells from human exfoliated deciduous teeth (SHEDs) were found to express STRO-1 and CD146, two early mesenchymal stem cell markers. The stem cell populations from primary teeth were found to have a higher proliferation rate than those from permanent teeth. Although primary human teeth contain stem cell populations, this is a minor component of the pulp cell population. Only 2% of the total primary cell population was found to be STRO-1 positive suggesting a relatively small population of stem cells within the primary tooth pulp. Although the authors report it was difficult to isolate pure stem cell populations from the primary tooth pulp, the upregulation of amelogenin in OECs when grown in coculture with the dental pulp cells from primary teeth (pDPCs), which includes a heterogeneous cell population of cells, suggests that these stem cells may not be necessary in large numbers to promote epithelial cell differentiation. The relatively few numbers of available pulp stem cells, the challenges in harvesting those stem cells, and the likely possibility that pulp stem cells are hematopoetically derived and could be much more easily obtained from blood or bone marrow, suggest that it is unlikely that dental pulp stem cells would be a primary source of cells for regeneration of other tissues. The ability of primary pulp stem cells to promote generation of tooth structures, including dentin and enamel, is more promising. Future research should include isolation and characterization of homogeneous populations of cells with in the dental pulp and their ability to regeneration tooth structures.
Summary of conclusions:
Mesenchymal stem cells can be isolated from primary tooth pulps. This heterogeneous population of cells can promote differentiation of fetal OECs into ameloblast lineage cells.
Assessment of article:
Good article with promising results. Good study design using many difficult microscopic and cell culturing techniques. The isolation of dental pulp cells from extracted primary teeth w/ moderate to severe caries may have had an effect on the numbers and viability of the stem cell line isolated in this study. Interesting stuff.
Wednesday, January 26, 2011
Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehab
Resident: Adam J. Bottrill
Date: 26JAN11
Region: Providence
Article title: Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehabilitation
Author(s): Watts, Amy K. DDS, MS
Journal: Pediatric Dentistry
Page #s: 414-419
Vol:No Date: 31:5, SEP/OCT 2009
Major topic: Local Anesthesia, General Anesthesia, Children
Minor topic(s): NA
Type of Article: Randomized, parallel-design study
Main Purpose: The purpose of this article was to evaluate the use of intraoperative local anesthetics in pediatric outpatient dental surgery. It assessed physiological stability, as defined by fluctuations in end-tidal CO2, HR, RR and subsequent anesthesiologist intervention.
Key points in the article discussion:
I. General:
A. Pain is both a real emotional and physiological respoonse
B. Research suggests that the use of regional anesthesia can reduce the amount of required inhaled general anesthesia.
C. LA, in conjunction with GA can produce a more hemodynamically stable patient AND control pain in the immediate post-operative period.
D. IDEAL ANESTHETIC AGENT: immobility, amnesia, , sedation, analgesia/nociception, arousal blockade with a pharmacological profile that possesses a wide margin of safety.
E. Currently, no guidelines by either the ASA or the ADA for use of local anesthesia during GA dental rehab. AAPD states that LA "may be used" to reduce pain in post-op period.
II. Methods:
A. Pilot study was conducted for feasability purposes
B. 48 children (mean age of 3.87) undergoing GA
C. Inclusion Criteria
1. 12-84 mo
2. at least one maxillary extraction.
3. rubber dam clamp in maxilla
4. at least one primary tooth needing pulp/crown
5. ASA I or ASA II
D. One dental anesthesiologist used for all GA's
E. Two groups: LA and NON-LA
F. LA administered prior to procedures (for LA group)
G. 2% xylocaine was given in the LA group
H. No patient exceeded 4.4mL of LA
I. Vital sign changes recorded 30 seconds after each procedure.
J. Anesthesiologist intervention was with 10 mg boluses of propofol
K. Intervention if: movement, breath holding, 20% increase in vital signs, ETCO2 <40mm Hg
B. Two groups: LA and NON-LA
C. LA administered prior to procedures (for LA group)
D. Vital sign changes recorded 30 seconds after each procedure.
III. Results/Discussion: (pooled data)
A. NON-LA group: changes in vital signs were statistically significant for two parameters.
1. Post extraction ETCO2
2. Post extraction HR
B. Interference: Different patients have different tolerability for changes in vital signs from baseline.
C. Weaknesses:
1. The exact amount of anesthesia received by each tooth was not able to be controlled.
2. Order of procedures was decided by the dentist.
IV. Conclusions:
A. Patients who were not given intraoperative local anesthesia were more likely to experience vital sign fluctuation requiring anesthesiologist intervention.
Assessment of article: I thought it was an efffective, thorough study. I wish there was more statistical significance to some of the other parameters and procedures. The conclusions seemed to only follow what is already known anecdotally. Despite this fact, it is nice to have an actual article backing up existing practice.
Date: 26JAN11
Region: Providence
Article title: Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehabilitation
Author(s): Watts, Amy K. DDS, MS
Journal: Pediatric Dentistry
Page #s: 414-419
Vol:No Date: 31:5, SEP/OCT 2009
Major topic: Local Anesthesia, General Anesthesia, Children
Minor topic(s): NA
Type of Article: Randomized, parallel-design study
Main Purpose: The purpose of this article was to evaluate the use of intraoperative local anesthetics in pediatric outpatient dental surgery. It assessed physiological stability, as defined by fluctuations in end-tidal CO2, HR, RR and subsequent anesthesiologist intervention.
Key points in the article discussion:
I. General:
A. Pain is both a real emotional and physiological respoonse
B. Research suggests that the use of regional anesthesia can reduce the amount of required inhaled general anesthesia.
C. LA, in conjunction with GA can produce a more hemodynamically stable patient AND control pain in the immediate post-operative period.
D. IDEAL ANESTHETIC AGENT: immobility, amnesia, , sedation, analgesia/nociception, arousal blockade with a pharmacological profile that possesses a wide margin of safety.
E. Currently, no guidelines by either the ASA or the ADA for use of local anesthesia during GA dental rehab. AAPD states that LA "may be used" to reduce pain in post-op period.
II. Methods:
A. Pilot study was conducted for feasability purposes
B. 48 children (mean age of 3.87) undergoing GA
C. Inclusion Criteria
1. 12-84 mo
2. at least one maxillary extraction.
3. rubber dam clamp in maxilla
4. at least one primary tooth needing pulp/crown
5. ASA I or ASA II
D. One dental anesthesiologist used for all GA's
E. Two groups: LA and NON-LA
F. LA administered prior to procedures (for LA group)
G. 2% xylocaine was given in the LA group
H. No patient exceeded 4.4mL of LA
I. Vital sign changes recorded 30 seconds after each procedure.
J. Anesthesiologist intervention was with 10 mg boluses of propofol
K. Intervention if: movement, breath holding, 20% increase in vital signs, ETCO2 <40mm Hg
B. Two groups: LA and NON-LA
C. LA administered prior to procedures (for LA group)
D. Vital sign changes recorded 30 seconds after each procedure.
III. Results/Discussion: (pooled data)
A. NON-LA group: changes in vital signs were statistically significant for two parameters.
1. Post extraction ETCO2
2. Post extraction HR
B. Interference: Different patients have different tolerability for changes in vital signs from baseline.
C. Weaknesses:
1. The exact amount of anesthesia received by each tooth was not able to be controlled.
2. Order of procedures was decided by the dentist.
IV. Conclusions:
A. Patients who were not given intraoperative local anesthesia were more likely to experience vital sign fluctuation requiring anesthesiologist intervention.
Assessment of article: I thought it was an efffective, thorough study. I wish there was more statistical significance to some of the other parameters and procedures. The conclusions seemed to only follow what is already known anecdotally. Despite this fact, it is nice to have an actual article backing up existing practice.
Tuesday, January 25, 2011
The effect of midazolam premedication on discharge time in pediatric
Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations
Author(s): Jason Horgesheimer, DDS, Charles Pribble, DDS, Ralph Lugo, PharmD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2001. V 23 No 6 491-494
Major topic: Effects of midazolam on discharge time after GA
Main Purpose: To evaluate the effect of oral premed w/ midazolam on recovery times of children undergoing dental restorations under GA
Overview of method of research:
The records of 106 children were retrospectively reviewed at Primary Children’s Medical Center in Salt Lake City Utah. All patients were ASA I or II. 50 children received .5mg oral midazolam approx. 30 minutes before the procedure. 56 children did not receive any premed. All children were mask inhalation induced with either nitrous, sevoflurane, or halothane. Also, all patients were nasotracheally intubated. Things taken into account in the study were time spent in the OR, post anesthesia care in the PACU, and time spent in the same day surgical suite.
Findings:
Oral midazolam is one of the most common pre-medications used in pediatric anesthesia practices today. It effectively decreases anxiety, produces amnesia, and facilitates anesthetic induction. Theoretically, midazolam has the potential to cause post op sedation and delay recovery from GA. However there is no clear consensus about this in the literature.
In this retrospective study there was no significant difference between the groups with respect to time spent in the OR, PACU, or SDS.
Key points/Summary:
Pre-op midazolam does not delay discharge of children undergoing GA.
Assessment of Article:
Good article. Right to the point. It shows that administering oral midazolam approx 30 min prior to anesthesia induction, the child receives the maximum post op benefit of anxiolysis and amnesia while not delaying discharge.
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations
Author(s): Jason Horgesheimer, DDS, Charles Pribble, DDS, Ralph Lugo, PharmD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2001. V 23 No 6 491-494
Major topic: Effects of midazolam on discharge time after GA
Main Purpose: To evaluate the effect of oral premed w/ midazolam on recovery times of children undergoing dental restorations under GA
Overview of method of research:
The records of 106 children were retrospectively reviewed at Primary Children’s Medical Center in Salt Lake City Utah. All patients were ASA I or II. 50 children received .5mg oral midazolam approx. 30 minutes before the procedure. 56 children did not receive any premed. All children were mask inhalation induced with either nitrous, sevoflurane, or halothane. Also, all patients were nasotracheally intubated. Things taken into account in the study were time spent in the OR, post anesthesia care in the PACU, and time spent in the same day surgical suite.
Findings:
Oral midazolam is one of the most common pre-medications used in pediatric anesthesia practices today. It effectively decreases anxiety, produces amnesia, and facilitates anesthetic induction. Theoretically, midazolam has the potential to cause post op sedation and delay recovery from GA. However there is no clear consensus about this in the literature.
In this retrospective study there was no significant difference between the groups with respect to time spent in the OR, PACU, or SDS.
Key points/Summary:
Pre-op midazolam does not delay discharge of children undergoing GA.
Assessment of Article:
Good article. Right to the point. It shows that administering oral midazolam approx 30 min prior to anesthesia induction, the child receives the maximum post op benefit of anxiolysis and amnesia while not delaying discharge.
Monday, January 24, 2011
Dental Fluorosis: Chemistry and Biology
Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Dental Fluorosis: Chemistry and Biology
Author(s): T. Aoba, O. Fejerskov
Journal: Critical Review of Oral Biology and Medicine.
Year. Volume (number). Page #’s: 2002 V 13, NO 2. 155-170
Major topic: Fluorosis (FL)
Overview of method of research: THOROUGH review
Findings:
Fluoride (Fl) is the most important caries preventative agent in dentistry today. An increase in various fluoride forms and vehicles has caused an increase in mild to moderate FL in many communities. The effect of Fluoride on enamel formation that causes FL in humans is cumulative. This review article was aimed at discussing the pathogenesis of FL in relation to a putative linkage between ameloblastic activities, secreted enamel matrix proteins/multiple proteases, growing enamel crystals, and fluid composition including Ca and Fl ions.
Enamel is very sensitive to free Fl ions. Once Fl is incorporated into the enamel matrix, the ion affects subsequent mineralization process by reducing the solubility of the mineral. Numerous human and animal studies hve proven that enamel hypomineralization in teeth w/ FL is mostly due to the aberrant effects of excess Fl on the rates at which enamel matrix proteins break down, and at which the rate of the by products are withdrawn from the maturing enamel. Any interference with enamel matrix removal could affect crystal growth, resulting in different magnitudes of enamel porosity at the time of eruption. As of right now (2002) there is no evidence that Fl affects proliferation or differentiation of the enamel organ cells, or the production and secretion of enamel matrix proteins/proteases within the dose range that can cause FL in humans.
The article contends that most likely, the Fl ion indirectly interferes with protease activities by decreasing free Ca concentration in the mineralization process. Ca regulation of these activities is extremely important.
Because the cariostatic effect of Fl is not due to its uptake by the enamel during tooth development, it is possible to obtain substantial caries reduction without a risk of dental FL.
Key points/Summary:
FL is caused by long term ingestion of Fl during tooth development. Even very low amounts of Fl intake may result in a low level of FL. The dose-response relationship is linear, and there is no critical threshold for Fl intake below which the effect on enamel will not be seen. Fl exerts its pathogenic role through alteration of Ca activities, and thereby Ca dependent proteases. More research is needed overall
Assessment of Article:
Very long, intense, specific, tedious article filled with an extreme amount of information. I had to read it three times to soak it all in. Biochemistry overload. I hope that the boards will be more general in asking a question about this… hopefully.
Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study
Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study
Author(s): Wayne Kan, BDsc, DClinDent, et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2009. V 32 NO 2. 134-140
Major topic: Taurodontism (TD)
Overview of method of research: 120 cases of children w/ TD were selected from a dental schools patient base. 83 of the children had hypodontia, and 37 children had supernumerary teeth. The crown-body root ratios of the permanent first molars of these children were compared with the same teeth in ‘normal’ case controls. The teeth were examined using the Seow and Lai technique. The teeth were outlined on an OPG and were traced by a single examiner.
Findings:
TD was first used to describe a characteristic molar trait seen in Neanderthal fossils. The definition of TD molars is teeth that have a tendency for the body of the tooth to enlarge at the expense of the roots. TD can be found in both primary and permanent teeth. TD can exist as either as an isolated trait or as a feature of multiple system malformation syndromes such as ectodermal dysplasia, Klinefelter syndrome, Down syndrome, trichodento-osseous dyplasia, and x-linked hypophosphatemic rickets, amelogenesis imperfecta and hypodontia. The etiology of TD is still unknown, however it has been proposed that it’s a result of disrupted developmental homeostasis, and involves a delayed invagination of Hertwig’s epithelial root sheath.
Key points/Summary:
In children with hypodontia, only the girls showed a significantly higher tendency for TD compared to the controls. This is likely to be a genetic issue, and possibly related to the x-chromosome. Boys with hypodontia showed a similar prevalence of TD to normal teeth. Children who had multiple missing teeth were significantly more likely to have TD than children who had one tooth missing. Conversely, TD in children with SN teeth was similar to the control group. Teeth with TD showed a higher prevalence of root resorption during ortho treatment, although this observation has not been confirmed. TD teeth also pose issue for endodontic and prosthodontic therapy (never place a post in a tooth with TD). More studies are needed on all of these subjects
Assessment of Article: Simple, basic knowledge article. Good information. Only one examiner makes the results standardized, but it also only gives us one persons view concerning the teeth. Most importantly, things to take away from this article for boards are
1. TD is associated with nonsyndromic hypodontia in girls, but not with nonsyndromic children with SN teeth
2. Children with multiple missing teeth are more prone to TD than a child who is only missing one tooth
Children’s Preference of Benzocaine Gel Versus the Lidocaine Patch
Resident’s Name: Jessica Wilson
Program: Lutheran Medical Center - Providence
Article title: Children’s Preference of Benzocaine Gel Versus the Lidocaine Patch
Author(s): Wu & Julliard.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2003. 25:4. 401-405.
Major topic: Topical Anesthetic Preference
Overview of method of research: Scientific Article
Background:
DentiPatch contains 46.1 mg lidociane (20% concentration), comes in unit dose 1cm x 3cm x 2mm patches and is applied after drying with gauze for 2.5 to 5 minutes with a maximum of 15 minutes in adults. Anesthetic effects take place in 5 minutes with maximum effects in 15 minutes. This delivery system has been shown to be effective in adults, but in children has been shown to decrease verbal indicators of injection pain when compared to topical gel.
Purpose:
To compare the pain, acceptance and preference associated with benzocaine gel and lidocaine patch (DentiPatch).
Methods:
This study included pediatric patients at Sunset Park Family Health Center at LMC in Brooklyn, NY with relatively non-contributory medical history, who demonstrated compliance with dental visits and demonstrated the need for bilateral topical anesthetic. These patients were required to have similar or identical treatment on both sides and identical local anesthetic administration on both sides.
On visit #1 the subjects were asked to choose between the 2 methods of topical anesthesia (DentiPatch with whimsical design or cherry flavored 20% benzocaine topical gel). The topical that was not chosen was then to be used at visit #2 which the child was informed of. One operator applied the topical and local anesthetic as well as performed the required treatment. The soft tissue was dried and the appropriate topical anesthetic was applied for 4 minutes with the DentiPatch first being cut in half to reduce the dosage of anesthetic.
2 different scales were used to measure comfort and pain, one subjective and one objective. The subjective scale was completed by the patient before the topical, after topical anesthetic administration and again after the injection if needed. At the first visit, the subjects were asked by the operator why they had chosen that mode of topical anesthesia and after the second visit which mode they liked best and why. The assistants conducting the objective scale were calibrated in 3 sessions with the operator.
Results:
30 subjects between 3 and 12 years old participated; 25 required local anesthetic. One the first visit 24 of 30 subjects chose the DentiPatch. After the second visit 22 preferred the DentiPatch. All 6 patients who originally chose the gel also stated that it was their favorite mode after the second appointment. At the first visit girls seemed to choose their mode based on appearance (61%) and boys because of novelty (88%), but it was concluded that age was the significant factor rather than gender.
Key points/Summary:
The DentiPatch was preferred by most children. Younger children chose the patch because of appearance whereas the older children chose it because of novelty and taste.
There were no significant differences in reported pain, but the objective scale values were higher for the gel than the patch indicating the DentiPatch was more effective in reducing pain.
Assessment of Article:
I thought this article was ok. The sample size was small, but the findings were interesting.
Program: Lutheran Medical Center - Providence
Article title: Children’s Preference of Benzocaine Gel Versus the Lidocaine Patch
Author(s): Wu & Julliard.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2003. 25:4. 401-405.
Major topic: Topical Anesthetic Preference
Overview of method of research: Scientific Article
Background:
DentiPatch contains 46.1 mg lidociane (20% concentration), comes in unit dose 1cm x 3cm x 2mm patches and is applied after drying with gauze for 2.5 to 5 minutes with a maximum of 15 minutes in adults. Anesthetic effects take place in 5 minutes with maximum effects in 15 minutes. This delivery system has been shown to be effective in adults, but in children has been shown to decrease verbal indicators of injection pain when compared to topical gel.
Purpose:
To compare the pain, acceptance and preference associated with benzocaine gel and lidocaine patch (DentiPatch).
Methods:
This study included pediatric patients at Sunset Park Family Health Center at LMC in Brooklyn, NY with relatively non-contributory medical history, who demonstrated compliance with dental visits and demonstrated the need for bilateral topical anesthetic. These patients were required to have similar or identical treatment on both sides and identical local anesthetic administration on both sides.
On visit #1 the subjects were asked to choose between the 2 methods of topical anesthesia (DentiPatch with whimsical design or cherry flavored 20% benzocaine topical gel). The topical that was not chosen was then to be used at visit #2 which the child was informed of. One operator applied the topical and local anesthetic as well as performed the required treatment. The soft tissue was dried and the appropriate topical anesthetic was applied for 4 minutes with the DentiPatch first being cut in half to reduce the dosage of anesthetic.
2 different scales were used to measure comfort and pain, one subjective and one objective. The subjective scale was completed by the patient before the topical, after topical anesthetic administration and again after the injection if needed. At the first visit, the subjects were asked by the operator why they had chosen that mode of topical anesthesia and after the second visit which mode they liked best and why. The assistants conducting the objective scale were calibrated in 3 sessions with the operator.
Results:
30 subjects between 3 and 12 years old participated; 25 required local anesthetic. One the first visit 24 of 30 subjects chose the DentiPatch. After the second visit 22 preferred the DentiPatch. All 6 patients who originally chose the gel also stated that it was their favorite mode after the second appointment. At the first visit girls seemed to choose their mode based on appearance (61%) and boys because of novelty (88%), but it was concluded that age was the significant factor rather than gender.
Key points/Summary:
The DentiPatch was preferred by most children. Younger children chose the patch because of appearance whereas the older children chose it because of novelty and taste.
There were no significant differences in reported pain, but the objective scale values were higher for the gel than the patch indicating the DentiPatch was more effective in reducing pain.
Assessment of Article:
I thought this article was ok. The sample size was small, but the findings were interesting.
Sunday, January 23, 2011
Clinical Solutions for Developmental Defects of Enamel and Dentin in Children
Resident: Roberts
Date: 1/26/11
Author: Shabtai Sapir
Journal: Pediatric Dentistry
Volume: 29 Number: 4
Year: 2007
Title: Clinical Solutions for Developmental Defects of Enamel and Dentin in Children
Discussion
Developmental defects of enamel(DDE) consist mainly of hypoplasia and of diffuse demarcated opacities. Fluorosis, Amelogenesis imperfecta, and even dentinogenesis imperfecta may be considered developmental defects of the enamel. Often times a patient who presents with DDE will complain of poor esthetics, thermal sensitivity, attrition, secondary caries, tooth discoloration, malocclusion and periodontal problems. It is upto the clinician to take into account the patients chief complaint and whatever other complications may present with the condition and treatment accordingly for the best result possible.
Prevention
When possible preventative treatment can an important step in managing a patient with DDE. This consist of early detection, often noted at the early eruptive stages of the 6 year molars as well as along with the anterior incisors. When detected, oral hygiene instruction may include proper toothbrushes and techniques as well as desensitizing toothpaste if necessary. A weekly topical fluoride gel or varnish application and daily sodium fluoride rinse may improve resistance to demineralization, decrease tooth sensitivity, and enhance enamel remineralization as well as post eruptive maturation. The use of a sealant early on may be appropriate when possible. Mechanical preparation of the enamel prior to application is not desirable unless integrity of the enamel has already been compromised
Thoughts about which adhesive system to use
The shear bond strength of resin composite bonded to hypo-mineralized enamel is significantly lower than bonding to normal enamel. Phosphoric acid, most commonly used for enamel etching, may cause more enamel loss than self-etching primers, reducing the adhesion to hypo-mineralized enamel. Self-etching adhesives( which are hydrophilic, bond chemically and micro-mechanically) may offer an alternative that better meets the challenge of adhesion to hypo-mineralized enamel.
Treatment
Treatment depends on the severity of the condition. A definite correlation between color and porosity, mineral content, and depth has been established. Yellow-brown defects tend to be deeper extending all the way to DEJ. Whereas white creamy defects are usually less porous and variable in depth.
mild cases of hypoplasia and fluorosis
Usually no treatment is indicated unless small and minor lesions exist. If this is the case enamel micro-abrasion can be performed but caution must be taken to not remove to much of the surface area compromising the integrity of the rest of the tooth. Fluoride applications and bleaching can also have a positive effect with these cases.
moderate cases of hypoplasia and fluorosis
Micro-abrasion may be considered. When moderately significant tooth structure is removed then a composite restoration should be considered to restore form and function. Self-etching primers are not recommended in moderate and severe fluorosis, as they provide a lower shear bond strength.
severe cases of hypoplasia and fluorosis
Crown restorations with resin composites, polycarbonate crowns, laminate veneers, or porcelain crowns may be indicated in these circumstances. If severe DDE is suspected the earlier the treatment the better the prognosis. For lesions not associated with fluorosis, self etching primer is preferred. When the defects involve proximal surfaces RSC can be very retentive and esthetic, when posterior teeth are involved or the state of hypoplasia is so severe polycarbonate or cast crowns is preferred and has been proven to be more durable. With severe fluorosis and AI a pre-rinse with 5% NaOCL can improve the mechanical and chemical bonding of the adhesive for better results.
Treatment of DI
The primary dentition is usually affected more often than the permanent dentition. Intracoronal restorations and veneers may be considered for anterior teeth. External bleaching has a history of producing positive results. Most posterior teeth are severe and require early restoration with SSC’s. In the anterior dentition RSC may not have good results due to adhesive problems. Anterior permanent teeth that erupt should however be covered with composite until they fully erupt to avoid attrition and then have a RSC, polycarbonate crown placed until a PFM crown can be placed at a later date.
Conclusion
Early detection and preventative measures may go along way to maintaining the health of a compromised dentition. Educating the parents so that definitive action can take place will be necessary for a good long term prognosis.
Factors Associated With Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities
Meghan Sullivan Walsh January 23, 2011
Literature Review - St. Joseph/LMC Pediatric Dentistry
Factors Associated With Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities
Resident: Meghan Sullivan Walsh
Program: Lutheran Medical Center- Providence
Article Title: Factors Associated with Parents’ Esthetic Perceptions of Children’s Mixed Dentition Fluorosis and Demarcated Opacities
Authors: Steven M. Levy, DDS, MPH; John J. Warren, DDS, MS; Barbara Broffitt, MS; Bethany Nielsen, BS
Journal: Pediatric Dentistry
Volume (number), Year, Page #’s; 27:6, 2005, pages 486-492
Major Topic: To present results concerning parent’s overall satisfaction with their children’s teeth with and without fluorosis and demarcated opacities.
Overview of Method of Research: The Iowa Fluoride Study is an ongoing longitudinal study of a cohort recruited at birth in 1992-1995 from postpartum units of eight Iowa hospitals. At the age of 7.7-11.9 years these subjects were given a dental examination and the parents completed a questionnaire to assess their satisfaction with their child’s dentition. The Fluorosis of these subjects was scored using the Fluoride risk index (FRI) dividing teeth into four sections of zones of teeth: 1) Incisal or occlusal table 2) incisal 1/3 3) Middle 1/3 4) cervical 1/3. The scores were evaluated in six separate categories. 1. 0 - no indication of fluorosis 2) 1-questionable fluorosis 3) 2-50% or more of the zone displayed fluorosis 4) 3- displayed pitting staining or deformity 5) 7- non fluoride opacity 6) 9- the surface zone was excluded due to poor visibility/lack of full eruption. Individuals were then classified into 3 different categories. 1) 2 or more teeth with at least one zone with a FRI score of 2 and 3 were considered to have “definitive fluorosis”; 2) a FRI score of 1 or with only one tooth with a score of 2 or 3 were both considered to have “questionable fluorosis” 3) no scores of 1,2, or 3 were in the “none” category. The questionnaire given to the parents contained three questions 1) Which of the following best describes your thoughts overall about the appearance of your child’s teeth? 2) If not ‘very satisfied’ which of the following are you concerned about? (choices included shape, color, alignment, spacing, crowding, speckled/blotchy, other 3) Which of the following best describes your thoughts overall about the color of your child’s teeth?.
Findings: Of the 577 children examined 37% had definitive fluorosis on one or more permanent incisors. 31% were classified as having definitive fluorosis, 54% had questionable fluorosis and 15% had none. Parent’s overall satisfaction decreased with higher fluorosis scores. Among those children with definitive fluorosis 50% of the parents had concerns about the color, as compared to 32% for those questionable fluorosis subjects and 40% for no fluorosis patients. 44% of the children with definitive fluorosis had parents who were concerned about the ‘blotchy’ appearance of their child’s teeth versus 21% of parents with children of ‘questionable’ fluorosis’ and 9% of parent whose children had no fluorosis. There was no significant relationship between occurrence of opacities and parent’s satisfaction with the overall color of their child’s teeth. In addition 60% of parents were concerned with alignment and 44-51% were concerned with crowding.
Key Points: Summary: Parents of children with dental fluorosis were less likely to be satisfied with the overall appearance of their child’s teeth versus parents with children who had no fluorosis. This study does show that fluoride does contribute to esthetic concerns for parents of children with fluorosis.
Assessment of the Article: The Iowa Fluoride Study is a great tool to study the relationship between fluoride exposure and the risks and benefits of intake. While this study did show that fluorosis does pose many esthetic concerns among parents there were many issues I had with this study. First, the age group selected for examination was that of mixed dentition patient which can result in parents having concerns in their child’s dentition for several reasons not necessarily that of fluorosis. A high percentage of parents had concerns with their child’s dentition who showed questionable of no signs of fluorosis. These numbers, while less than those children with fluorosis, show a questionable assessment of a parent’s view of their child’s dentition. In addition, parents were just as concerned with alignment, spacing, crowding, etc. as they were with dental opacities and fluorosis. The study will pose much more sound when these patients are in full permanent dentition and can take a questionnaire based on the assessment of their own dentition.
Wednesday, January 19, 2011
N2O/O2 versus O2 use during Conscious Sedation
Resident: Swan
Article Title: The Physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients
Author: Leelataweewud, et al
Journal: Pediatric Dentistry, Volume (Number): 22:2, 2000
Major Topic: Conscious sedation using an oral narcotic regimen with adjunctive oxygen or nitrous oxide/oxygen
Type of Article: Scientific article
Main Purpose: compare the effects of N20/O2 versus O2 as adjuncts to an oral narcotic regimen during pediatric conscious sedation
Background: The use of N20/O2 as an adjunct during CS is a widely practiced and well-researched technique, although some studies do indicate that N20 use can compromise the airway of a sedated child. Supplemental O2 administration during CS has also been the subject of previous research—the thinking behind it is that supplemental O2 elevates arterial oxygen tension to much higher levels than normal and also increases residual functional capacity, providing an O2 reserve in the case where a child’s breathing slows or stops during sedation. (preventing desaturation, or a drop in SpO2 of 5% from baseline in an immobile, quiet patient.) Studies have supported this use of supplemental O2. Other studies comparing the two techniques have shown no difference in physiologic parameters (PR, SpO2, RR), with better sedation using nitrous.
Overview of method of research: 19 children were included in this randomized double-blind crossover stud. Each child served as their own control by either receiving O2 or N2O/O2 supplementation during two operative visits. The investigators were blinded as to this initial assignment. Baseline vitals were taken for each patient, and all patients were given an oral regimen of 50 mg/kg chloral hydrate, 25 mg hydroxyzine, and 1.5 mg/kg meperidine. 45 minutes after administration, the kids were transferred to the operatory, papoosed, and attached to monitors. Treatment was planned so that each of the two visits would have comparable difficulty and length, but if patients were well-sedated and cooperative, the operator did as much work as possible. PR, RR, SpO2, and end-tidal CO2 were measured every 5 minutes. The PI recorded levels of sedation during the appointments using an AAPD approved subjective scale. The overall sedation outcome was assessed at the end using another subjective scale. Data were statistically analyzed.
Findings: The differences in PR and SpO2 between different visits were not statistically significant, while effect on RR was marginally significant (N2O actually increased RR in this study). There were more desaturation events using N2O/O2, but the difference was not significant (mean of 5.9 events for N2O appts, 3.6 in the O2 group). Level of sedation was higher with the N2O group, and this finding was statistically significant. The final evaluations of the sedations were as follows: with O2 use, 42% excellent, 37 % unsatisfactory, and 21% unsatisfactory. With N2O use, 69%, 26%, and 5% respectively.
Key Points/Summary:
1. No difference in physiologic parameters was noted during treatment.
2. N2O did not increase risk of desaturation but did increase frequency of desaturation events and airway repositioning after desaturation episodes.
3. N2O deepened sedation levels with this narcotic regimen
4. N2O improved sedation outcomes
5. When N2O is used, children should be monitored very closely
Assessment of Article:I had not heard of O2 supplementation during CS, but it appears N2O provides much better sedation as one may assume. The subjectivity of the assessment scales used is a potential limitation, but is the most feasible method of evaluation. I thought it was a good study overall.
Article Title: The Physiological effects of supplemental oxygen versus nitrous oxide/oxygen during conscious sedation of pediatric dental patients
Author: Leelataweewud, et al
Journal: Pediatric Dentistry, Volume (Number): 22:2, 2000
Major Topic: Conscious sedation using an oral narcotic regimen with adjunctive oxygen or nitrous oxide/oxygen
Type of Article: Scientific article
Main Purpose: compare the effects of N20/O2 versus O2 as adjuncts to an oral narcotic regimen during pediatric conscious sedation
Background: The use of N20/O2 as an adjunct during CS is a widely practiced and well-researched technique, although some studies do indicate that N20 use can compromise the airway of a sedated child. Supplemental O2 administration during CS has also been the subject of previous research—the thinking behind it is that supplemental O2 elevates arterial oxygen tension to much higher levels than normal and also increases residual functional capacity, providing an O2 reserve in the case where a child’s breathing slows or stops during sedation. (preventing desaturation, or a drop in SpO2 of 5% from baseline in an immobile, quiet patient.) Studies have supported this use of supplemental O2. Other studies comparing the two techniques have shown no difference in physiologic parameters (PR, SpO2, RR), with better sedation using nitrous.
Overview of method of research: 19 children were included in this randomized double-blind crossover stud. Each child served as their own control by either receiving O2 or N2O/O2 supplementation during two operative visits. The investigators were blinded as to this initial assignment. Baseline vitals were taken for each patient, and all patients were given an oral regimen of 50 mg/kg chloral hydrate, 25 mg hydroxyzine, and 1.5 mg/kg meperidine. 45 minutes after administration, the kids were transferred to the operatory, papoosed, and attached to monitors. Treatment was planned so that each of the two visits would have comparable difficulty and length, but if patients were well-sedated and cooperative, the operator did as much work as possible. PR, RR, SpO2, and end-tidal CO2 were measured every 5 minutes. The PI recorded levels of sedation during the appointments using an AAPD approved subjective scale. The overall sedation outcome was assessed at the end using another subjective scale. Data were statistically analyzed.
Findings: The differences in PR and SpO2 between different visits were not statistically significant, while effect on RR was marginally significant (N2O actually increased RR in this study). There were more desaturation events using N2O/O2, but the difference was not significant (mean of 5.9 events for N2O appts, 3.6 in the O2 group). Level of sedation was higher with the N2O group, and this finding was statistically significant. The final evaluations of the sedations were as follows: with O2 use, 42% excellent, 37 % unsatisfactory, and 21% unsatisfactory. With N2O use, 69%, 26%, and 5% respectively.
Key Points/Summary:
1. No difference in physiologic parameters was noted during treatment.
2. N2O did not increase risk of desaturation but did increase frequency of desaturation events and airway repositioning after desaturation episodes.
3. N2O deepened sedation levels with this narcotic regimen
4. N2O improved sedation outcomes
5. When N2O is used, children should be monitored very closely
Assessment of Article:I had not heard of O2 supplementation during CS, but it appears N2O provides much better sedation as one may assume. The subjectivity of the assessment scales used is a potential limitation, but is the most feasible method of evaluation. I thought it was a good study overall.
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