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.

Jason Hencler 12/18/09
Guideline for Periodontal Therapy

Chronic inflammatory periodontal diseases (PD) are treatable

Better understanding of mechanisms of PD progression and pathogenesis has made treatment more effective and predictable

Goals of Periodontal Therapy:
· Preserve natural dentition and periodontium
· Maintain and improve periodontal health, comfort, esthetics, and function

Periodontal exam should include:
· Extra- and intraoral exam to detect non-periodontal oral diseases or conditions
· General periodontal exam
· Assessment of the presence of plaque, calculus, and gingival inflammation
· Dental exam (caries, proximal contacts, existing restorations, tooth mobility)
· Occlusal evaluation
· Diagnostic PA and BW radiographs
· Evaluation of potential periodontal systemic inter-relationships

Establish diagnosis, treatment plan, and prognosis

PD and conditions
· Gingivitis: gingival inflammation without attachment loss or with non-progressing attachment loss. Other gingival diseases may be modified by systemic factors, medications or malnutrition.
· Periodontitis: (Slight, moderate, severe, localized, generalized) gingival inflammation with progressing attachment loss
o Chronic PD
o Aggressive PD
o PD as a manifestation of systemic disease
o NUG
o Perio/endo
· Abscesses of the periodontium
· Developmental or acquired deformities and conditions

Development of a Tx plan:
Used to establish the methods and sequence of delivering periodontal tx and follow-up and maintenance program
May include: med consult, adjunctive specialty consults, and chemotherapeutic agents

Informed consent and patient records:
Any foreseeable risks, potential complications or failure with tx should be explained and consent should be obtained b/f

Treatment procedure:
· Patient/parent education, OHI
· Prophy, SCRP to remove supra- and sub-gingival plaque and calculus
· Post-tx evaluation and reinforce OH
Additional tx that may be indicated
· Chemotherapeutic agents
· Resective procedures (pocket reduction, gingivectomy)
· Periodontal regenerative procedures (grafts)
· Periodontal plastic surgery (for soft tissue defects
· Occlusal therapy
· Pre-prosthetic periodontal procedures (exploratory, site development)
· EXT’s
· Implants
· Procedures to facilitate orthodontic tx (tooth exposure, frenulectomy)
· Management of periodontal systemic interrelationships

Periodontal maintenance therapy (individualized):
Establish an appropriate interval for periodontal maintenance therapy according to assessment of current OH status and current evaluation of periodontal status

Factors modifying results:
May be adversely affected by circumstances beyond the control of the dentist
Periodontal therapy may be compromised:
1. Systemic disease
2. Inadequate plaque control
3. Pulpal/periodontal problems
4. Failure of patient to follow suggested tx or maintenance program
5. Adverse health factors such as smoking, stress, and occlusal dysfunction

Evaluation of Therapy
· Patient counseled on why and how to perform effective daily OH
· Therapeutic procedure have been performed to arrest PD
· SCRP has left no calculus and rough root surfaces
· No bleeding on probing
· Recommendation has been made for correction of any factor contributing to PD
· Appropriate periodontal maintenance program has been recommended to patient for long-term control

Guideline on Antibiotic Prophylaxis for Dental Patients at Risk for Infection

Boboia

Background

Bacteremia is anticipated following invasive dental procedures. Only a limited number of species are implicated in postoperative infections. In 2007 the AHA revised the guidelines for the prevention of IE and reducing the risk of resistant strains of bacteria.

Primary Reasons for Revision:
· “IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities then from bacteremia caused by dental, GI tract, or GU tract procedure”. These daily activities are defined as tooth brushing, flossing, chewing, and use of tooth picks.

· Prophylaxis may prevent an exceedingly small number of cases of IE

· The risk of antibiotic associated adverse events exceeds the benefit

· Maintenance of optimal health and hygiene may reduce the incidence of bacteremia from daily activities and is more important then prophylaxis

Recommendations

Patients with Cardiac Conditions

Prosthetic heart valves, history of IE, unrepaired cyanotic congenital heart disease (CHD), completely repaired congential heart defect with prosthetic material or device during the first 6 months after the procedure, repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop valvulopathy. Also patients with a history of IV drug abuse

Antibiotics are recommended for all dental procedures that involve manipulation of gingival tissue of the periapical region of teeth or perforation of the oral mucosa. Please refer to manual or reference guide for dosage information

Patients with Compromised Immunity

Patients with compromised immune systems may not be able to tolerate bacteremia. This may include patients with:

HIV, severe combined immunodeficiency (SCIDS), neutropenia, immunosuppresion, sickle cell anemia, status post splenectomy, chronic steroid use, lupus, diabetes, status post organ transplant

Patients with: shunts, indwelling vascular catheters, or medical devices

· AHA recommends antibiotic prophylaxis only at the time of placement of these devices

· Ventriculoatrial (VA) or Ventriculovenus (VV) shunts for hydrocephalus are at risk of bactermia-induced infections; require prophylaxis

· Ventriculoperitoneal (VP) shunts are not at risk for infection; don’t require prophylaxis

· Plates, pins, screws does not require antibiotic prophylaxis; total knee replacement does not routinely require this either

· Antibiotics may be considered when high risk dental procedures are performed on patients within 2 years following implant surgery or for patients with previous joint infections

Guidelines on Pediatric Restorative Dentistry

Resident’s Name: Brian Schmid DMD Date: 12/11/09
Article title: Guidelines on Pediatric Restorative Dentistry
Author(s): Clinical Affairs Committee - AAPD
Journal: Pediatric Dentistry Clinical Guidelines Reference Manual 2006-2007
Month, Year: 2007
Major topic: Restorative dentistry in children
Type of Article: Review
Findings: Poor, rural and minority children are at greater risk for caries mostly due to limited access to care. DMFS scores higher than the patients age, numerous white spot lesions, low SES, cariogenic diet, high caries rate in siblings or parents and the presence of dental appliances are predispose children to caries. Tooth morphology including relative pulp size and dental dimensions make pediatric restorative care different from adult care. SSC’s are recommended for primary teeth which have received pulp treatments, except in cases with conservative pulpal access and exfoliation expected within the next 2 years. Dentin and enamel bonding has been proven equally successful in primary and permanent teeth, allowing for more conservative restorations, provided that manufacturers directions are followed. One, two and three bottle systems have all been found to be successful. Sealants are highly successful at stopping cares causing bacteria into pits and fissures of primary and permanent teeth, where 80% of childhood decy occurs. Enameloplasty and pre-op fluoride application have neither improved nor undermined successful sealant placement. High risk surfaces should be sealed first and with proper isolation. You can seal over incipient lesions as long as proper follow-up in maintained. Currently, glass ionomer is not recommended as a long term sealant. Glass ionomers, however, do uptake and release fluoride, are more moisture tolerant, biocompatible and have a similar coefficient of expansion as tooth structure. Fluoride turnover may continue for as long as 5 years. GI is recommended for use as luting cement, cavity base/liner, restorations in primary teeth, Class III and IV restorations in permanent teeth and caries control including ART. Resins and composites are more esthetic but have more complex handling properties and lower long term integrity. They come in a variety of filler size and concentration which affects their polishability, esthetics and strength. They are contra-indicated in patients where isolation is impossible or patients with poor OH/unavailable for followup. Amalgam restorations have long history of successful but are now being replaced by more esthetic, but less effective alternatives. It is recommended for Class I and II restorations, provided the interproximal box does not extend beyond the proximal line angles, in which case an SSC is recommended. SSC’s are an excellent option for large carious lesions, pulp treated primary teeth or in patients with rampant decay and/or special needs. Veneered SSC’s are available but are often less retentive and liable to loss of facing. Veneers can be used on teeth with developmental or acquired defects. Full coverage PFM’s are a good option for highly carious permanent teeth as well as intra-osseous implants, but growth and changes in occlusion must be taken into account before this track is taken. Fixed and removable prosthetic devices may be used for esthetics, orthodontics, space maintenance etcetera.
Assessment of article: Great overall review of biomaterials, some techniques and indications/contraindications.

Guidelines - Deep Sedation / GA

Resident’s Name: Joanne Lewis Date: December 11, 2009

Guideline on Use of Anesthesia Care Providers in the Administration of In-office Deep Sedation/General Anesthesia to the Pediatric Patient

Background

- Many pediatric dentists would like to provide deep sedation/general anesthesia outside of the traditional surgical setting.

- Utilizing deep sedation/general anesthesia in the dental office offers benefits for the patient and the dental team.

- It is well documented that treating the patient in an appropriate outpatient facility is a safe and viable approach.

Recommendations

- In-office deep sedation/general anesthesia requires at least 3 people – the anesthesia care provider, the treating dentist, and an assistant.

- It is the responsibility of the treating dentist to verify the credentials of the anesthesia care provider.

- The operating dentist and clinical staff need to maintain current expertise in basic life support. An individual experienced in recovery care must be in attendance until the patient exhibits stable vital signs for discharge. The staff of the treating dentist must be well versed in emergency protocols.

- The facilities in which the dentist practices must meet the guidelines and appropriate state codes for administration of the highest possible level of sedation/anesthesia.

- Minimal monitoring equipment for deep sedation includes a blood pressure monitor, pulse oximeter, precordial stethoscope, capnograph, and electrocardiograph. In addition, for general anesthesia, a temperature monitor and pediatric defibrillator are needed.

- Documentation requirements vary from state to state; however, at a minimum, vital signs, drugs used, and recovery period need to be documented.

- High-risk patients should be treated in a facility properly equipped to provide for their care.

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnositc and Therapeutic Procedures

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures

Important Definitions

Minimal sedation: (anxiolysis) pt responds normally to verbal commands; ventilatory and cardiovascular fxn unaffected.

This can be done by the practitioner alone.

Moderate sedation: (conscious sedation) pt responds purposefully to verbal commands either alone or accompanied with light tactile stimulation. Interactive state for older patients, and age appropriate behaviors for younger patients (expect crying). No intervention needed to control airway. CV function is usually maintained. Practitioners must protect pt airways and if the pt’s reflexes don’t protect the airway, consider it a deep sedation.

additional support personal must be present.

recovery must be monitored in a facility until discharge criteria has been met. young children should be able to stay awake for at least 20min in a quiet environment.

Deep sedation: pt is not easily aroused, but respond purposefully after repeated verbal or painful stimulation. Ability to maintain ventilatory function may be impaired. CV function is usually maintained. Complete or partial loss of protective airway reflexes may be lost.

the state and risks may be indistinguishable from general anesthesia.

trained person is required to administer and monitor. must have electrocardiograph and defibrillator. vascular access is required.

recovery is same as for moderate sedation

Goals:

guard pt safety and welfare

minimize physical discomfort and pain

control anxiety, minimize psychological trauma, amnesia

control behavior/movement

return patient to safe state

Always use the lowest dose of drug with the highest therapeutic index for the procedure.

Combining drugs is ok, but the use of 3 or more is associated with increase in adverse reactions

Candidates:

ASA class 1 or 2 for minimal, moderate or deep sedation.

ASA classes 3 or 4 require special consideration and consultation with anesthesiologist is recommended

Prescription medications intended to accomplish procedural sedation must not be administered without the benefit of direct supervision by trained medical personnel.

Responsible person:

Obviously sedated patients must be accompanied, but it’s best to have 2 adults present.

Facilities

must have immediate personnel and equipment to manage emergency and rescue situations

most adverse rxns are compromised airway, depressed respirations, even hypotension and cardiopulmonary arrest: must be able to treat these complication in a sedation facility.

Back-up

protocol for back-up emergency services must be identified. ready EMS notification will work, but availability of EMS services doesn’t replace the practitioner’s responsibility to provide initial rescue in managing life-threatening complicaions.

On-site monitoring and rescue equipment

emergency cart must be accessible. use appendix C and D for drugs and equipment lists.

Documentation before sedation

Informed consent

Instructions: written and verbal

Considerations for post-op observation

24-hour telephone access for patients

Dietary Precautions

for elective sedation use general anesthesia fasting guidelines as listed in Table 1.

for emergency sedation: must balance benefit vs. risks of aspiration

Use of Immobilization Devices

papoose must not obstruct airway or restrict chest. a hand or foot should always be exposed.

Documentation at time of sedation

Health evaluation must be done: there is a list of all items that should be included. Very similar to our current H&P (minus Does the patient have lice?)

herbal medicines and strongly affect cytochrome P450 systems and result in prolonged drug effect and altered blood drug concentrations

Documentation during treatment

time based record

time-out to start

include durgs and dosages as well as inspired oxygen and vitals

Documentation after treatment

use generally recognized scales to determine when patient is ready for release.

use recognized discharge criteria

be careful when using anecdotes that resedation does not occur.

Preparation: SOAPME

Suction

Oxygen

Airway

Pharmacy

Monitors

equiment or drugs

If you are going to aim for a particular level of sedation you must be prepared to handle the next deeper level or sedation.

Special considerations:

LA: must not overdose. Also max dosages can affect sedation levels. aspirate frequently to avoid intravascular injections.

New pulse oximeters are better than old ones

Capnography can be very helpful to monitor respiratory activity

LMA (laryngeal mask airway) is an new airway device that you should seek training in.

Intraosseous injection: another adjunct that may be useful

N2O

considered minimal sedation at levels under 50% when used alone.

when used in higher concentration than 50% moderate sedation can be achieved

some guidelines for usage are outlined.

Guideline on the Use of Antibiotic Therapy of the Pediatric Dental Patients

Guideline on the Use of Antibiotic Therapy of the Pediatric Dental Patients

AAPD Reference Manual V31, No. 6, 2009-10

Intro: Widespread use of antibiotics has resulted in resistance of common bacteria to antibiotics therefore necessitating conservative use of such antibiotics.

Wound Healing: Host factors such as age, systemic disease, malnutrition,and type of wound (clean, potentially contaminated, or dirty) all determine the need for antibiotics. Facial lacerations may require topical antibiotics. Intraoral lacerations contaminated by extrinsic bacteria, open fractures,and joint injuries are at increased risk of infection and thus require antibiotics. If antibiotics are needed, it should be given as soon as possible for the best result in the most effective route whether IV, IM, or oral. Antibiotics should be given for a minimum of 5 days beyond the time of significant improvement.

Special conditions:
Dental origin: If a child presents with acute symptoms of pulpitis, then treatment should be rendered, and usually antibiotics are not indicated. In this situation, the child should have no systemic signs of infection like a fever or facial swelling.

Facial swelling of dental origin: Antibiotics are indicated when there is evidence of facial swelling, and treatment is required immediately.

Dental trauma: Local application of antibiotics to the root of an avulsed tooth with an open apex with less than 60 Minutes of drying time. Systemic antibiotics are indicated with avulsions, usually tetracycline in older individuals and penicillin in younger patients.

Pediatric periodontal disease: Antibiotics are usually indicated due to inadequate immune response to protect against the growth of periodontal pathogens. Culture and susceptibility tests of isolate is helpfule .

Viral disease: Only use antibiotics if one suspects a secondary bacterial infection.

Oral Contraceptive use: Use caution when prescribing antibiotics on patients taking oral contraceptives as the antibiotics decrease the effectiveness of oral contraceptives. Tetracycline and penicillin like medications as well as Rifampicin all decrease plasma levels of ethinyl estradiol , causing ovulation.

Policy on the Management of Patients with Cleft Lip/Plalate and other craniofacial anomalies

Policy on the Management of Patients with Cleft Lip/Plalate and other craniofacial anomalies

Reference Manual: 2009-10

AAPD endorses the statements of the American Cleft Palate-Craniofacial Association (ACPA). In 1991 parameters of care were listed for these patients
1. Management of these patients is best provided by an interdisciplinary team of specialists.
2. Care is best provided by a team with experience in treating a number of patients with craniofacial abnormalities.
3. Best time for a initial evaluation is within the first few weeks of life
4. The team should make every effort to assist the family in adjusting to the birth of the child with various anomalies and the future demands and stress placed on the family.
5. The family should be well informed about treatment decisions and options should be given to encourage participation in these decisions.
6. The team approach to treatment planning recommendations is necessary
7. Care recommended by the team should be provided at the local level as best as possible, and more complex procedures reserved for major medical centers that have experienced providers.
8. Team must be sensitive to extrinsic demographic factors.
9. The team must monitor short-term and long-term outcomes of care.
10. Outcomes must account for satisfaction, psycho-social well-being of the patient as well as the effects on growth, function and appearance.

Dental specialists should also coordinate care between pediatric dentists and orthodontic, oral and maxillofacial surgery and prosthodontic specialists.

Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Guideline on Use of Nitrous Oxide for Pediatric Dental Patients

Background
· Nitrous is a colorless and virtually odorless gas with a faint sweet smell. It’s effective as an analgesic/anxiolytic agent causing CNS depression and euphoria with little effect on the respiratory system. It’s taken up rapidly and absorbed quickly for alveoli. Diffusion hypoxia can occur because it is 34 times more soluble than nitrogen in blood. Children can desaturate faster then adolescents which is why administration of oxygen 3-5 minutes post-op is important.

Disadvantages
· Lack of potency
· Dependant largely on psychological reassurance
· Interference of the nasal hood with injection to the anterior maxillary region
· Pt must be able to breath through the nose
· Occupational exposure hazards

Patient Selection
· Fearful / anxious patient
· Mentally, physically, or medically compromised
· Gag reflex
· A cooperative child undergoing a large procedure
· If profound anesthesia cannot be found

Assessment
· Allergies / previous allergic reaction
· Current meds, dose, time, route, and administration site
· Disease, disorders, or physical abnormalities
· Previous hospitalizations

Contraindications
· Comes COPD
· Emotional disturbance or drug related dependencies
· First trimester pregnancy
· Treatment with bleomycin

Technique
· Flow rate 5 to 6 L/min
· Bag should pulsate gently with each breath and should be neither over- or underinflated.
· 100% O2 for 1-2 min followed by nitrous in 10% intervals; 50% concentration should routinely not be decreased
· 100% O2 for 3-5 minutes post-op
Monitoring
· Clinical observation: resposiveness, color, respiration rate and rhythm, response to commands

Adverse effects of nitrous oxide/oxygen inhalation
· Excellent safety record with rare incidence of adverse reactions
· Nausea and vomiting is the most common adverse effect occurring in 0.5% of cases
· Fasting is not required for patients undergoing treatment under nitrous; the practitioner may recommend that a light meal be consumed in the 2 hours prior to nitrous administrations.
· Diffusion hypoxia can result from a rapid release of N2O from the blood stream into the alveoli, thereby diluting the O2 concentration. This may lead to headache and disorientation (can be avoided by administration of O2).

Documentation
· Informed consent should be obtained and documented in chart
· Patients record should include indication for use of nitrous oxide / inhalation, nitrous oxide dosage, duration of the procedure, and post treatment oxygenation procedure

Facilities / personnel / equipment
· All equipment must be able to deliver 100% O2 (never less then 30%)
· Fail-safe system that is checked and calibrated regularly according to state laws
· Practitioner and personnel must have appropriate credentials
· BLS required
· Emergency cart/kit must be accessible; emergency equipment must be able to accommodate peds
· Positive-pressure O2 delivery system capable of >90% O2 administration at a 10L/min flow rate for at least 60 min. is needed

Guidelines on Adolescent Oral Health Care

Resident’s Name: Brian Schmid DMD Date: 12/4/2009
Article title: Guidelines on Adolescent Oral Health Care
Author(s): Clinical Affairs Committee
Journal: Pediatric Dentistry
Month, Year: 2006-2007
Major topic: Adolescent health care
Type of Article: Review
Key points/Summary: Adolescent is loosely defined as patients 10-18 y.o. of which there are almost 40 million individuals in America. They have particular needs including: potentially high caries rate, increased risk for traumatic injury and periodontal disease, poor nutrition, increased esthetic desire and awareness, orthodontic treatment, dental phobia, initiation of tobacco use, pregnancy, eating disorders and unique social and psychological needs.
Fluoride supplements are recommended until age 16, after which fluoridated water and dentifrices provide appropriate systemic and topical coverage. Emphasis on oral hygiene is essential as many children will fall off the wagon come adolescence. Adolescent diet is often high in refined sugars and acdic beverages. Dietary analysis and coaching is important. Sealants are still recommended for patients of this age especially those at risk for pit and fissure caries. Recare and prophylaxis, including regular radiographs should be a part of adolescent life. In cases of ANUG or other acute soft tissue infection, referral to a specialist may be necessary; orthodontic care is often associated with periodontal disease putting adolescents at an even higher risk and necessitating even more preventive education. Evaluation of 3rd molars can be an acute or long term problem for adolescents and should be checked regularly and treated in due time. Treatment planning and referral are essential to properly treat TMJ, missing teeth or ectopically erupting teeth. A mouthguard should be fabricated for any adolescent participating in contact sports or any sport where significant oral and facial trauma is possible. The prevention of tobacco use, access t safe dental bleaching protocols, supporting positive life experiences, supporting the sometimes jarring effects of psychosial development of an adolescent and helping them transition to adult care is essential for a pediatric dentist treating an adolescent population.
Assessment of article: Very thorough and a good reference for adolescent care.

Infant Oral Health Care

Resident’s Name: Joanne Lewis Date: December 4, 2009

Guideline on Infant Oral Health

Background

- More than 40% of children have caries by the time they reach kindergarten.

- High caries rates occur in families; the children of mothers with high caries rates are at a higher risk of caries.

- It is well documented that there is vertical colonization of S mutans from mother to infant and that the acquisition of S mutans occurs at an average age of approximately 2 years.

- Modification of the mother’s oral flora at the time of the infants colonization can impact the child’s caries rate.

- The primary goal of early risk assessment is to screen for parent-infant groups who are at risk of ECC and who would benefit from early aggressive intervention.

- The ideal approach to infant oral health care is the early establishment of a dental home.

- Anticipatory guidance for the caregiver before and during the colonization process includes:

o Oral hygiene

o Diet

o Fluoride

o Caries removal

o Delay of colonization

o Xylitol gum

Recommendations

- All primary health care professionals who serve mothers and infants should provide caregiver education on the prevention of ECC. Oral health counseling during pregnancy is especially important.

- The etiology of ECC, oral health risk assessment, anticipatory guidance, and early intervention should be included in the curriculum of all medical, nursing, and allied health professional programs.

- Every infant should receive an oral health risk assessment from his/her primary health care provider by 6 months of age.

- Parents or caregivers should establish a dental home by 12 months of age.

- Health care professionals should support the establishment of a dental home for all infants by 12 months of age.

Management of Persons With Special Health Care Needs

From Pediatric Dentistry vol. 28 No. 7 reference manual

Guideline on Management of Persons with Special Health Care Needs

Summary by Kris Hendricks

Purpose: AAPD accepts its responsibility to assist in treating this patient population

SHCN definition:

individuals who “have a physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs. The condition may be developmental or acquired and may cause limitations in performing daily self-maintenance activities or substantial limitations in a major life activity. Health care for special needs patients is beyond that considered routine and requires specialized knowledge, increased awareness and attention, and accommodation.”

SHCN patients are more vulnerable to oral disease than the general population.

SHCN disorders that are specifically manifest in the orofacial complex:

• amelogenesis imperfecta
• dentinogenesis imperfecta
• cleft lip/palate
• oral cancer

Disorders that include orofacial problems:

• osteogenesis imperfecta
• ectodermal dysplasia
• epidermolysis bullosa

AwDA defines the dental office as a place of public accommodation. Failure to comply and accommodate SHCN patients is a violation of federal and/or state law.

Difficulties for SHCN patients:

• lack of financial resources
• lack of timely care can lead to more costly episodic care
• medical benefits don’t extend to cover the dental needs
• other health care needs may seem more important than dental
• limited transportation
• complex behavioral problems
• anxiety
• tough to transition these patients from care of pediatric dentist to generalist as they mature

Recommendations:

• strong phone triage at initial contact
• create a dental home--makes SHCN pts less likely to suffer from dental disease
• patient and parent education
• complete med history--updated at every recall
• comprehensive exam and caries risk assessment
• med consults as needed
• must make attempts to communicate with hearing/speaking impaired
• informed consent
• proper behavior management/protective stabilization/sedation/general anesthesia
• be cognizant of psychological well-being of SHCN patients
• make appropriate referrals for things you cannot treat

Preventative strategy

• education of patient and parent
• daily supervision of OH regimen
• Fluoride dentifrice
• electric toothbrush
• dietary counseling
• sealants

Guideline on Oral and Dental Aspects of Child Abuse and Neglect

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Boboia Date: 12/4/09
Article title: Guideline on Oral and Dental Aspects of Child Abuse and Neglect
Author(s):
Journal: Pediatric Dentistry Reference Manual
Volume #; Number; Page #s): 28:7
Year: 2007
Purpose Review the oral and dental aspects of physical/sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions.
Abstract
In all 50 states, physicians and dentists are required to report cases of abuse and neglect to law enforcement agencies. This report addresses: bite marks, perioral and introral injuries, infections, and disease suspicious for child abuse or neglect. Physicians recieve minimal training in oral health and dental injury and may therefore not detect certain aspects of abuse as readily as they do on other parts of the body.
Physical Abuse:
Craniofacial, head, face, and neck injuries occur in more then half of the cases of child abuse. Signs of neglect (caries, gingivitis, and other oral health problems) should also be reported. Some authorities believe the oral cavity may be a central focus for physical abuse because of its significance in communication and nutrition. Injuries may be inflicted with instruments such as eating utensils, bottle (during force feeding), hands, fingers, scalding liquids, or caustic substances. Contusions, burns, oral lacerations, fractured / displaced teeth, and facial bones / jaw fractures are all common findings among abuse cases. One study showed the lips were the most common site (54%) for inflicted injuries (followed by the oral mucosa, teeth, gingiva, and tongue). Unintentional or accidental injuries to the mouth must be distinguished from abuse by using the history, timing, and mechanism of injury (as well as the child’s developmental capabilities and characteristics of the injury).
Sexual Abuse:
Oral-genital contact suspicion necessitates a referral to a specialized clinic equipped to conduct a comprehensive examination. Oral / perioral gonorrhea in prepubertal children is pathognomonic for sexual abuse but rare among prepubertal girls evaluated for sexual abuse. Pharyngeal gonorrhea is usually asymptomatic. HPV is a little tricky when attempting to determine a mode of transmission to the oral region. Vertical and horizontal modes of transmission through non-sexual contact does occur.
Bite Marks:
Should be suspected when ecchymoses, abrasions, or lacerations are found in an elliptical or ovoid pattern. Animal bites tear flesh and human bites compress flesh (rarely causing tissue avulsion). Photographs should be taken where the angle of the camera lens is directly over the bite and perpendicular to the plane of the bite to avoid distortion. Swabbing the bite for DNA and taking a PVS impression of it are also very helpful forensic tools. Photographs and documentation should be repeated for at least 3 days to document the evolution of the bite. Involvement of a forensic odontologist or pathologist to evaluate and document the bite pattern is appropriate.
Dental Neglect:
Def: “willful failure of a parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection”. “The point at which to consider a parent negligent and to begin intervention occurs after the parent has been properly alerted by a health care professional about the nature and extent of the child’s condition, the specific treatment needed, and the mechanism of accessing the treatment”.

Conclusions:
The Prevent Abuse and Neglect Through Dental Awareness phone # is (501) 661-2595 or email Lmouden@healthyarkansas.com

Microabrasion

Resident’s Name: Joanne Lewis Date: November 20, 2009

Article title: Microabrasion: effect of time, number of applications, and pressure on enamel loss

Author(s): Daniel P. Dalzell, DDS, MS, et al

Journal: Pediatric Dentistry

Volume (number): 17(3)

Month, Year: 1995

Major topic: microabrasion

Type of Article: scientific article

Main Purpose: To evaluate the effect that time, number of applications, and pressure has on the amount of enamel loss seen in micoabrasion using hydrochloric acid and pumice.

Overview of method of research: 27 extracted premolars with no visible signs of decalcification, fluorosis, or any other defect were used in the investigation. The teeth were hand rubbed with an 18% HCL-pumice mixture at time intervals of 5, 10, and 20 sec and 5, 10, and 15 applications under pressures of 10, 20, and 30g. Longitudinal sections were cut from the treated sections and measured for enamel loss.

Findings: Enamel loss significantly increased as each variable increased. The combination of 10 ten-sec applications or 15 five-sec applications with 20g of pressure resulted in enamel loss of slightly less than 250 mm.

Key points/Summary: When using this procedure, keep the applications below 10 ten-sec applications or 15 five-sec applications.

Assessment of article: I have never used this procedure – anyone else?

Bleaching Primary Teeth with 10% Carbamide Peroxide

Department of Pediatric Dentistry

Lutheran Medical Center

Date: 11/20/2009

Article title: Bleaching primary teeth with 10% carbamide peroxide

Author(s): Brantley, Barnes, Haywood

Journal: Pediatric Dentistry

Volume (number): 23:6

Month, Year: 2001

Major topic: Bleaching

Minor topics: Primary tooth trauma

Type of Article: case report

Main Purpose: Review of a case in which primary teeth were bleached.

Overview of method of research: case report

Findings:

Primary teeth can be safely bleached

Key points/Summary :

Parents requested treatment to lighten anterior teeth in their 4 year old daughter after a trauma caused darkening of the teeth.

A custom suckdown beaching tray was fabricated.

10% carbamide peroxide was used

10% carbamide peroxide is also used in infants for throat infections and is thought to be safe for ingestion.

There were no radiographic abnormalities in the injured teeth.

The teach were bleached for 1 hour a day for 2 weeks and produced some whitening, but not significantly.

After the 2 week period, the parents began having the child sleep with the tray in every 3rd night. for 2 more weeks . (total wear time 47 hours)

The teeth brightened to a satisfactory level after the 4 week period.

The teeth exfoliated normally and there were no noted side effects.

Assessment of article: I’m definitely going to try this in the clinic. I’ve had parents complain about dark teeth post trauma and this seems harmless. I’ve also had parents request bleaching for their kids with naturally ugly teeth. I think some people will find this ridiculous.