The oral cavity in Crohn's disease

Authors: Pittock, Drumm, Fleming, McDermott, Imrie, Flint, Bourke

Journal: Journal of Pediatrics

Date: May 2001

Main Topic: Crohn’s Disease

Purpose: To assess the utility of oral examination as part of the diagnosis of patients with Crohn’s disease.

Summary: In this investigation, 48% of newly diagnosed patients with Crohn’s disease had oral lesions. When biopsied, 75% of the lesions contained non-caseating granulomas. No surprises here: “patients with oral CD had more oral symptoms.”

Oral manifestations are common in children, so oral examination can assist in the diagnosis of Crohn’s disease.

Findings:

This was a retrospective chart review over 5 years done at a hospital for sick children. They went back and looked at the presence of oral ulcerations in children who were diagnosed with Crohn’s disease. They then analyzed the date to come up with their findings.

Crohn’s is an inflammatory bowel disease characterized by granulomatous inflammation affecting the GI tract from mouth to anus. The oral lesions look similar to apthous or those in ulcerative colitis, and their presence alone is not diagnostic. Diagnosis depends on clinical presentation and histopathology. A pediatric dental surgeon can be used to identify and biopsy these lesions.

The presence of oral lesions did not correlate with the severity of the disease.

My take: good information to have for differential diagnosis of oral ulcerations.

How to distinguish between neglect and deprivation abuse

Resident: Adam J. Bottrill
Date: 23AAPR10
Region: Providence
Article title: How to distinguish between neglect and deprivation abuse
Author(s): Golden, M. H. et al.
Journal: Archives of Disease in Childhood
Page #s: pp. 105-107
Year: 2003; 88
Major topic: Neglect and deprivation abuse
Minor topic(s): NA
Type of Article: Discussion paper

Main Purpose: Assist the practitioner in clearly distinguishing between cases of neglect and deprivation abuse.
Overview of method of research: N/A

Key points in the article discussion:

I. General:
A. The authors reject completely the idea that these two situations are linked.
B. Neglect: is a non-deliberate failure to supply needs of the child.
C. Deprivation: is the deliberate or malicious failure to supply the needs of a child.
1. forced isolation (imprisonment), food deprivation (starvation), witholding love (emotional abuse)

II. Special features of neglect:
A. Only the person responsible for the child’s needs can be neglectful.... but ANYONE can be abusive.
B. Neglect can only be determined based on the needs of a “normal child”
C. Each level of society may have a different interpretation of what constitutes neglect.
D. Neglect is much more common and is directly related to knowledge and awareness of caretaker.
E. There is universally some degree of neglect by ALL caretakers.
F. Independent person can not be neglected.
G. Severe neglect warrants intervention but is usually due to impoverished circumstances.
H. Can also be a result of the failure of a child to signal his needs.
I. Typical for a malnourished child to have a passive flat affect. Cry is an important part of a “normal child.’
1. This passivity can lead to even further neglect because of lack of signaling “need.”

III. Wider picture:
A. Not only individuals have the ability to neglect.
1. Society, government, organizations
2. The conundrum of circumcision

IV. What to do:
A. Education of both “carers” and society.

Assessment of article: Informative but not really “Scientific.”

Management of Crohns Disease

Brian Schmid DMD

Authors: Doug Knutson MD, Greg Greenberg MD and Holly Cronau MD
Journal: American Family Physician
Date: August 2003, vol 68 Number 4
Main Topic: Overview of Crohns Disease
Summary: Crohns is an inflammatory disorder of the alimentary canal. The incidence peaks in the 20's and 40's. Etiology is unknown but is related to enviromental, genetic, immunologic and infectious causes. It is more common in whites than blacks, in women than in men and in Jewish vs. non. Smokers are also more affected. Symptomas include chronic or nocturnal diarrhea, abdominal pain, bowel obstruction, weight loss, fever and night sweats. Differential includes: acute appendicitis, small bowel obstruction, ulcerative colitis, irritable bowel syndrome, malabsorption syndromes, infectious or ischemic colitis, neoplasia, hemorrhoids and diverticular disease.
Therapy includes easing flareups and maintain remission. Mild to moderate disease: treated with salicylate preparation and/or antibiotics. Success of these treatments is dependent on the location of the inflammation and different formulations target specific sites of the alimentary canal. Metronidazole is used but caution must be maintained due its connection with peripheral neuropathy. Ciprofloxacin is also used.
Moderate to severe disease: Steroid treatment is indicated. Azathioprine (Imuran) and mercaptopurine (Purinethol) are often used. Infliximab, an antibody to human tumor necrosis factor alpha, is used in patients who do not respond to these drugs. Steroid therapy continues until symptoms go into remission, often taking months. Side effects such as diabetes mellitus, adrenal suppression and osteoporosis limit their long term use. Budesonide is also becoming a popular alternative and is comparable to prednisolone. Immunosuppressants can be used in addition to steroids. Infliximab is used when other courses have failed.
Severe Disease: Parenteral steroids are called for. Abdominal CT followed by surgical intervention may be necessary, although not curative.
Stress has been associated with Crohns flareups. Patient may be taking vitamin supplements due counteract malabsorption. Frequent colonic monitoring may be necessary depending on severity of disease.
Summary: Great overview of a horrible disease.

Oral manifestations of tube fed patients and management of patient

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 5/07/2010
Article title: Dental Care for children fed by tube: a critical review
Author(s): Dyment et al.
Journal: Spec Care Dent
Month, Year: 1999:19 220-4
Major topic: Oral manifestations of tube fed patients and management of patient.
Type of Article: Literature review
Purpose: This article provides a literature review to describe oral signs of patients being tube fed and the management of these patients in terms of calculus build-up, caries, oral hypersensitivity, and risks of pneumonia.
Overview: Calculus: Review of literature indicates that there is no significant difference in terms of plaque formation of children on a feeding tube and those who eat via the oral route, yet there was a significant increase in calculus formation in the tube fed children. Another study revealed that despite daily hygiene practices, calculus build up was still greater in the tube fed sample Caries rates have not been studied. The pH of the saliva was greater in oral fed group than in tube fed group when given a sucrose and carbohydrate drink. The tube fed group had lower counts of strep, lactobacillus, and filmentous bacteria. Perio disease has not been studied. Dental erosion related to Gastro-esophageal reflux is not common because of the possibility of calculus protecting the teeth. However, GER is common in children fed by a tube as well as with patients less than 40 years of age with severe central nervous system dysfunction Oral hypersensitivity often develops in children who are tube fed and thus a program of oral stimulation such as regular oral hygiene at home and dental care in the dental office. Relevance of oral health to general health: Many tube fed children have neuromuscular impairment which may compromise their protective airway reflexes. In this case, the patient is at increased risk of aspiration and pneumonia. It is believed that chronic poor oral hygiene, reduced salivary flow, and increased calculus can lead to increased numbers of anaerobic plaque which is implicated in pneumonia. The best prevention for pneumonia may be aggressive oral hygiene. Risks of dental treatment include aspiration and subsequent pneumonia. Prevention of aspiration during dental treatment include posturing patient by positioning the patient vertically if possible with the neck elongated to open the airway. Use of head restraints and moth-props may negate the patients ability to protect their airways. Use of low viscosity liquids like water are difficult for the neurologically challenged patient to tolerate. Water spray from ultrasonic scalers, handpieces, and air water syringes should be limited. Frequent breaks are advised
Summary: The goal of dental care is lower the pathogenic bacteria in secretions which could be aspirated and thus lead to pneumonia. The frequency of professional dental cleanings should be determined on a case by case basis and treatment goals should be limited to shorter more frequent visits to avoid fatigue. Optimal oral health may decrease the morbidity and mortality of tube fed patients due to aspiration pneumonia.
Assessment of article: Good article with common sense conclusions.

05/14/2010 Tobacco use among middle and high school students

Resident: J. Hencler
Date: 05/14/2010

Article title: Tobacco use among middle and high school students

Source: CDC/MMWR 11/14/2003, 52(45); 1096-1098, 2002

Major topic: Tobacco use

Type of Article: Survey

Background:
Each day in the US, approximately 4,400 youths aged 12-17 years try their first cigarette. An estimated 1/3 of these young smokers are expected to die from a smoking-related disease.

Main Purpose: Assess tobacco use among middle and high school students.

Overview of method of research:
246 schools participated in the survey, which included 26,119 students (12,581 middle school students and 13,538 high school students)

Findings:
Both tobacco and cigarette smoking among high school students (9-12) decreased 18% during 2000-2002, however a decrease among middle school (grades 6-8) was not significant.

Key points in the article discussion:
The decline in cigarette smoking and tobacco use among high school students has reflected reflects a downward national trend since 1997 but a decrease among middle school students was not significant. Why middle school and high school students appear to be responding differently to the current anti-smoking environment is not clear. The findings in this study are subject to two limitations. First, these data only apply to youth who attended middle school or high school and are not representative of all youths in these age groups. Second, the data were from self-reports of survey participants. The data in this report suggest that further refinements in evidence-based strategies will be needed to decrease tobacco use among middle school students. 1) Devising more targeted and effective media campaigns, 2) reducing depictions of tobacco use in entertainment media, 3) instituting campaigns to discourage family and friends from providing cigarettes to youths, 4) promoting smoke-free home, 5) instituting comprehensive school-based programs and policies in conjunction with supportive community activities, and 6) decreasing the number of adult smokers to present more non-smoking role models.

Summary of conclusions:
Because tobacco use is the leading cause of preventable death in the US, efforts to reduce tobacco use must remain a public health priority. Preventing tobacco use among youth is essential to reduce future smoke-related illness and associated costs. However, in 2003, states cut spending for tobacco use prevention and control programs by $86.2 million. For the decline in tobacco use among youth in the US to continue, such funding must be restored and perhaps expanded.

Assessment of article:
Good info, nothing new. Good to see tobacco use is declining though.

Resident: J. Hencler
Date: 05/07/2010

Article title: Oral health considerations in muscular dystrophies (MD)
Author(s): Balasubramaniam, Sollecito, Stoopler
Journal: Spec Care Dentist 28(6) 2008

Major topic: MD and oral/dental considerations
Type of Article: Review

Main Purpose: Present oral health considerations in MD patients.

Background:
MD’s are a heterogenous grp of inherited neuromuscular disorders characterized by muscle necrosis and progressive muscle weakness. Severity of the disease range from mild to severe, and is caused by mutations in genes that encode for proteins that are critical for maintaining muscle fiber integrity for functional muscle contraction and relaxation. There is no specific tx for any of the MDs and it is considered an incurable disease. In pts suspected of having MD, percussion of the tongue w/ a tongue depressor and the occurrence of lingual myotonia may confirm the presence of MD in some cases.

Orofacial Manifestations:
The muscles of the head and neck are affected by MD and manifest as altered craniofacial morphology and dental malocclusion. Weakness of perioral muscles may produce deformities of the face and difficulty in chewing and phonation. MD patients usually have long, thin faces, high-arched palates mandibular prognathism, and dental malocclusion. The most consistent clinical finding is malocclusion related to vertical aberrations in craniofacial growth due to reduced function of the masticatory muscles and the less affected suprahyoid muscles. The resultant lowering of the mandible and tongue does not counterbalance the forces from the stretched facial musculature. This change in force balance affects the teeth transversely, decreases the width of the palate, and causes posterior crossbite. The combo of lowering of the mandible and relative decrease in bite force permits the overeruption of posterior teeth and development of anterior open bite and deep palatal vault. Delayed eruption of the permanent dentition seen in MD patients may be related to the calcification stages of dental devel. There have been few reports on TMJ abnormalities in patients with MD. OH declines with loss of muscle function of the arms and hands.

Dental Management Considerations:
Consultation w/ patient’s physician to determine stability of MD and presence of complications such as cardiomyopathy, arrhythmias, pulmonary hypoventilation, and neuropsychiatric traits. Patients with stable MD may receive tx in outpt setting, however persons w/ severe muscle contracture and/or med complications may require tx under GA. GA may cause complications b/c the risk of malignant hypertension (MH) associated w/ certain neuromuscular blocking agents. In general, neuromuscular blocking agents should be avoided. Induction and maintenance with N20, inhalation agents, barbiturates, and benzodiazepines may be used usually w/out complication. Proper pt positioning may be difficult due to kyphoscoliosis or flexion contractures. Post op complications are typically pulmonary related. Pt should be inclined at 45 degress post op to prevent dyspnea and obstruction. In the outpt setting, MD pts ofter require assistance w/ ambulation. MD patients should not be put in supine position and b/c of facial and/or perioral muscle wealness require vigilant suctioning of fluids to prevent aspiration. OH is usually poor due to limb weakness. Potential for drug interaction and oral manifestations w/ commonly used meds for MD pts such as prednisone must be considered.

Recommendations:
Routine dental visits and good OH habits established early. Education for pt/caregiver regarding proper diet, OH, fluoride, sealants, and recall visits. Children w/ MD w/ low caries risk can begin tooth brushing at the age of 1 w/out toothpaste, and at age of 3, toothpaste, topical F prophylaxis, and F varnishes should be introduces. Children w/ MD that are mod-high risk for caries should receive F varnish at 6 month and 3-6month intervals, respectively. The indication for ortho tx to improve masticatory funct is difficult to determine as progressive devel of the dentofacial abnormalities in MD renders prognosis unpredictable. MD patients require special considerations when providing their OH care. Oral healthcare providers need to familiarize themselves with the orofacial characteristics and dental tx considerations for pts w/ MD so that they can deliver safe and appropriate tx.

Assessment of article:
Good article. Good to be aware of the OH characteristic of patients w/ MD and the tx challenges one would face while tx a MD child.

Latex allegry

Resident’s Name: Joanne Lewis Date: May 7, 2010

Article title: The Dental Team and Latex Hypersensitivity

Author(s): ADA Council on Scientific Affairs

Journal: JADA Vol. 130, Feb. 1999

Type of Article: association report

Main Purpose: to address issues relating to latex hypersensitivity among dental team members.

Overview: Since the 80’s, there has been an increase in reports of latex sensitivity/reactions. Factors include: increased use of latex products, latex products with higher protein content due to insufficient leaching times during manufacturing, aerosolization of cornstarch powder that binds with the latex protein antigen, and heightened cumulative exposure. 3 types of reactions: 1.) Type I hypersensitivity is the antibody-mediated allergy to latex protein, symptoms include skin redness, hives, itching, runny nose, itchy eyes, anaphylaxis. Type IV hypersensitivity is the allergic contact dermatitis caused by an immunological reaction to chemicals added to latex and synthetic gloves during the manufacturing process, symptoms include dry cracked skin, vesicles. Irritant dermatitis can be confused with the other 2 but is the result of skin irritation due to exposure to chemicals used in the workplace or insufficient rinsing or drying of hands. Prevalence of true latex protein allergy (Type I) is unclear (3.8-6.2% among dental professionals) – studies suggest that among health care workers, irritant dermatitis, rather than protein allergy, is the most common skin condition associated with frequent glove use. Look for the ADA’s Seal of Acceptance when selecting gloves to be sure the gloves meet the ADA’s guidelines for safety and efficacy.

Key points/Summary: Dentists should reduce occupational exposure for themselves and their team as much as possible.

Oral Conditions in Children with Cerebral Palsy

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 5/07/2010
Article title: Oral Conditions in Children with Cerebral Palsy
Author(s): Rodrigues MTB,Masiero D, Novo NF., et al
Journal: J Dent Child. 70: 40-46
Month, Year: 2003
Major topic: CP and prevalence of dental caries, plaque index, time of eruption of permanent teeth, malocclusion, bruxism and oral skills.
Type of Article: Research article
Purpose: This article evaluates the prevalence of dental caries, plaque index, time of eruption of permanent teeth, malocclusion, bruxism in a group of children with Cerebral Palsy compared to normal children.
Overview of method of research: 62 children with CP and 67 controls were subdivided into mixed or permanent dentition as well as gender and evaluated for dental caries, plaque index, time of eruption, malocclusion,bruxism and oral skills to detect issues related to chewing and swallowing. Oral skills were evaluated by speech therapist relating to how children performed sucking, biting/breathing functions, and presence of residual food during eating.
Results and Discussion: In the study, 68% of CP children had spastic quadriplegia or spastic diplegia. Children with CP had significantly more decayed and missing surfaces and higher DMFS scores in the 12-16 year old patients, while the younger group was not significantly different.. Dental plaque was significantly higher in both females and males in the permanent dentition group. Although not significant, there was a tendency for delayed eruption of permanent molars in the CP group. There was a significantly higher percentage of malocclusion in females in the mixed CP group, as well as males in the older group, mostly described as Class II anterior open bite. Males in the older group with CP had significantly higher reports of bruxism.. Presence of residual food and mouth breathing were significantly higher in the CP group. It was thought that higher caries rate in permanent dentition of the CP group was related to higher presence of residual food
Conclusion: the conclusions are described in the results
Assessment of article: Good article with no surprising conclusions.

Cerebral Palsy Diagnosis and Management: The state of the Art

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Craig Elice Date: 5/07/2010
Article title: Cerebral Palsy Diagnosis and Management: The state of the Art
Author(s): Murphy N> Such-Neibar T.
Journal: Curr Probl Pediatr ADosesch Health Care
Month, Year: May/ June 2003
Major topic: Definition of CP and classification of CP
Type of Article: Review article
Purpose: This article reviews all facets of CP
Overview: Cerebral Palsy is defined as abnormal movement and posture caused by a non-progressive lesion of the brain. It has a prevalence of 1 to 2.3 per 1000 live births and occurs in 1 of 20 live infants with extreme prematurity. However 7 of 10 CP children reach full term gestational term. CP is classified by limb involvement and quality of movement disorders as described by resting muscle tone and resistance felt to slow passive movement of limbs. Monoplegia involves a single limb; Diplegia affects mostly the lower extremities; Hemiplegia involves one side of the body with arms being affected more than the legs; Quadriplegia affects all 4 limbs. Movement is defined by Spasticity which represents 75% of affected children; Hypotonia which is rare and often leads to other types of CP: and Hyperrelexia and clonus which demonstrates increase in tone of muscles. The types combine both limb involvement and movement disorders. Spastic Quadriplegia CP is most disabling. Only 1/3 of affected children ever ambulate. Frequently have oral motor dysfunction leading to aspiration and other secondary medical complications Spastic Hemiplegia CP shows itself as asymmetric limb use by 6 months of age. Most often learn towalk by 2 years of age. Spastic Diplegia is most often associated with pre-term birth. Affects motor tone and control of lower extremeties yet learn to walk by 3 years of age. Extra-pyramidal CP develps distinct movement characteristics by 12-18 months of age. Often normal intelligence yet speech impairment is severe. Occurs due to Kernicturis (elevated bilirubin) and its affect onbasal ganglia and auditory nuclei. Risk factors: Uncertain in 50% of case. Documented risk factors include maternal MR, birth weight < 2KG, and fetal malformation. Death of one twin increases risk of CP in the surviving twin. Perinatal asphyxia is a factor in 8-10% of keds. Full term infants of normal birth weight may have cerebral malformation, prenatal strokes or infection. Cystic Periventricular leukomalacia (PVL) is the best independent predictor of CP. Diagnosis is difficult in early years of life but as child misses developmental milestones and primitive reflexes persist, it becomes clearer. The best predictor of pre-term infants is the presence of echodensities and cysts in the periventricular white matter regions of the brain. Therapeutic interventions include neurodevelopmental treatment which was not shown to be effective, Patterning which was used historically. It involves using exercises to improve neurological organization and slow ly build upon these milestones. Conductive education to educate children to control their bodies and overcome limitations. Not effective! Hyperbaric oxygen which did not work, and lastly, Forced use or Constrain Induced Movement which involves restraining the stronger unaffected side to favor the weaker extremity, This method has been shown to be effective. The authors describe interdisciplinary care incorporating multiple specialties and to focus on family centered care. Early intervention is criticalusing repetitive exercises to improve acquisition and expression of motor skills. Other items of interest include 90% of children show oral motor impairment and GI issues in 80-90%. Growht delays often occur as a result of malnutrition. Tube feedings lead to weight gain and in many cases improved immune competence, alertness and responsiveness Baclofen is an effective drug to reduce spasticity which decreases reflux, improves sleep. Other issues include compromised bladder function, constipation and drooling in 25-35% of patients. Spasticity Management: PT and OT facilitate range of motion exercises, strength, coordination, and functional activities. Botulinum toxins are injected into regions of spastic muscles to decrease spasiticity, with minimal side effects. Baclofen is the most common antispasticity drug used in children. Othopedic procedures include lengthening of chonically shortened muscles from spastic contractures. These procedures are usually delayed until after 5 years of age. Selective dorsal rhizotomy of sensory rootlets that are controlling muscle spasticity. This treatment is usually effective in higher functioning diplegic CP who have good strength, balance, and range of motions yet have limited function due to spasticity. Intrathecal Baclofin therapy is very effective as the medication is pumped directly into the spinal fluid. The life expectancy is related to the mobility and feeding skills of the patient. More severely disabled children reach 20 years of age before respiratory infections, seizure disorders and aspiration events lead to death. Higher functioning patients with CP with fewer compromised systems generally achieve a normal life expectancy.
Conclusion: General review article that classifies CP, and describes the different systems that can be affected and how it is currently treated
Assessment of article: Very long article probably representative of a broad description of CP .

Dental Management of Children with Latex Allergy

Department of Pediatric Dentistry

Lutheran Medical Center

Kris Hendricks Date: 05-07-10

Article title: Dental management of children with latex allergy

Author(s): S. M. Hashim Nainar

Journal: International Journal of Paediatric Dentistry

Volume (number): 11

Month, Year: 2001

Major topic: Latex Allergy

Minor topics: Patient Management

Type of Article: Informative

Main Purpose:

Review of management of children with latex allergy

Overview of method of research:

Review of the literature.

Findings:

Latex allergy has serious consequences for the dental management of patients with certain medical conditions. Providers need to be aware of the many varying sources of latex in the dental environment which could cause an allergic reaction.

For skin rash, treat with 1%Hydrocortisone. For anaphylaxis use epi 1:1000 IM or 1:10,000 IV and notify EMS immediately.

Key points/Summary :

Latex allergy was first reported in the dental literature in 1993.

Latex allergy could be the main cause of anaphylactic shock during surgery in children.

Latex allergy has shown cross-reactivity with various food allergies including avacoado, banana, chestnut, kiwi, potato and tomato.

High risk factors for latex allergy in children include:

• spina bifida, atopy, first surgery before age 1, history of multiple surgeries, congenital urologic abnormalities, gastrointestinal malformations, hydrocephalus internus, ventriculo-peritoneal shunts, spinal cord injuries, family history of atopy.

Good history includes asking about any allergies to toys or other things the children have contact with.

Management

1. Treat latex allergy pt first
2. designate a latex free operatory
3. Have a latex free emergency cart
4. Avoid dental products that may contain latex including items in the waiting room.
5. Autoclave latex free items seperate from latex containing items
6. Allergy pts needing significant amounts of dental work are best treated under general anesthesia in a latex free OR.

Assessment of article:

Good read on latex allergies. The only thing not mentioned was the latex prophy cup which has come up on boards in the past.

Neuropathic chewing in comatose children

Resident: Adam J. Bottrill
Date: 23AAPR10
Region: Providence
Article title: Neuropathic chewing in comatose children
Author(s): Ngan, Peter W., Nelson, Linda P.
Journal: Pediatric Dentistry
Page #s: pp. 302-306
Year: 1985, Dec
Major topic: Neuropathic Chewing Etiology
Minor topic(s): Management of this parafunction
Type of Article: Topic review and suggested management

Main Purpose: Review and discuss etiology and management of neuropathic chewing.
Overview of method of research: N/A

Key points in the article discussion:

I. General:
A. Patients in a coma may develop chewing movements similar to those sleeping. If the coma is prolonged, they might inflict trauma on themselves... “neuropathis chewing”
1. It is possible for various appliances to aid these patients.

II. Methods:
A. Retrospective study on 16 comatose patients with neuropathic chewing at CHOP.
B. Appliances were made for 10 of the patients.

III. Coma
A. Cause by interruption of the integrity of the arousal system.
B. Either brain stem injury or diffuse cortical injury.
C. Masticatory movements are normally rhythmic and automatic.
D. Comatose patients have lost the ability to coordinate these movements.
E. It has been written that a bolus placed between the teeth can trigger chewing. In comatose pt’s the tongue can cause this “reflex”.

IV. Management of Neuropathic Chewing:
A. Suggested indications for the need of fabricating dental appliance:
1. Presence of ruminatory movements of the jaw or bruxism which is usually of more than 24-hr duration.
2. Presence of intraoral soft tissue lacerations.
B. Other potential solutions include a bite block or mouth prop.
1. …though I have a hard time keeping them in place on CONSCIOUS kids.
2. Can be used as a temporary fix
C. Removable custom made appliance.
1. 2nd most hygienic
2. Allows tongue movement but prevents it acting as a bolus.
3. Need to paralyze patient for impression.
D. Intermaxillary fixation NOT recommended
1. Not hygienic
E. Consider NOT making an appliance as more mildly comatose patients have self-limited chewing.
.














Assessment of article: There is no post-treatment analysis for the appliance treatment. This seems like a pretty severe shortcoming for such a “respected” author…. I’m calling shenanigans.

Facial Nerve Paralysis: report of two cases of Bell’s Palsy 5/7/10

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Facial Nerve Paralysis: report of two cases of Bell’s Palsy
Author(s): Keels DDS, Martha. Linwood Long, Jr. DDS. Willie Vann, Jr. DMD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 1987. 9(1) 58-62
Major topic: Facial nerve paralysis in children
Overview of method of research: Discussion of 2 cases of Bell’s Palsy(BP)

Findings: Facial nerve paralysis(FNP) is a important and serious cause of morbidity in children, with it’s presentation being quite nerve-racking(no pun intended). FNP can be a sign of an underlying disease. The most common cause of FNP is BP, a unilateral paralysis. Causes of BP are debated, however it is suggested that it may have something to do with Herpes simplex or zoster, nerve compression, venous ischemia, an IAN block gone awry, and narrowing of the bony canal. There is a familial tendency. BP is rare in kid’s younger than2, and is slightly more common on females than males. Signs of BP include widening of the affected palpebral fissure, flattening of nasolabial fold, inability to the eye completely, inability to purse the lips, and drooping of one corner of the mouth. Pain and numbness are reported as well.

Treatment
The most important thing to do is to care for the eye. Artificial tears during the daytime, and a nighttime patch are necessary to prevent corneal abrasion. For chronic BP, steroid therapy and surgical nerve decompression may be necessary. 75% of cases regress spontaneously with full recovery, 15% have satisfactory recovery w/ some neurological deficit, and 10% have permanent paralysis.

Case one was an 11yo male who complained of not being able to smile. It was the first time this had happened to the child. There was no history of trauma. The child’s PCP referred him to an ophthalmologist, who made the diagnosis of BP. Drops were prescribed for the eyes with nighttime patch wear. One month after onset, the BP was hardly noticeable, and after 3 months, there was a full recovery.

Case two was an 8 year old male who presented with what his mom described as ‘a crooked jaw’. The pediatric dentists who saw the child referred him to their PCP for possible BP. The PCP confirmed, and no treatment was recommended. The child’s symptoms did not improve. Approx 2 weeks after the initial diagnosis, the child began choking on a piece of food. The child was brought to the hospital and treated for the incident. At the hospital, numerous tests were conducted. Eventually a diagnosis of pontine glioma was made. The child was treated with radiation. The child eventually died of complications 12 months after the initial diagnosis. Wild.

Key points/Summary: We as pediatric dentists may be the first healthcare providers to see children who present with symptoms of BP. While an extremely small percentage of children who present with FNP have brainstem tumors, it’s our job to make a prompt, proper referral to the PCP.

Assessment of Article: Scary stuff. I’m not even going to say the ‘S’ word

Latex allergies in children with spina bifida: relevance for the pediatric dentist

Brian Schmid DMD 5/7/10

Journal: Pediatric Dentistry
Date: Jan/Feb 1994
Vol: 16(1) 18-22
Main Topic: latex allergies in spina bifida patients
Summary: Children at high risk for latex allergy: spina bifida and myelodysplasia, exstrophy of the bladder and other deemed to have a likelihood of multiple genitourinary operations and urinary catheterizations, neurologicaly impaired bladders.
There have been at least 16 fatalities due to latex allergy in the US. Beyond latex gloves, some of the most common dental supplies containing latex that may be overlooked are radograph packets and rubber dams. 4 cases are presented concerning latex allergies in pediatric dental patients.
Case 1: A pt with myelomeningocele and urinary incompetence developed an allergy despite multiple previous exposures with no reaction. Allergic skin testing revealed a serious alergy to latex. Vinyl gloves were used in addition to a rubber dam made from a cut up vinyl glove and dental treatment was carried out without incident.
Case 2: 10 year with spina bifida developed a latex allergy which required emergency intervention in the form or diphenhydramine without further complications.
Case 3: Presention of a 7 year old with a known latex allergy who had a reaction during the exposure of bitewing radiographs at a private dental office. It was later found that the packet contained no latex, and the allergy was most likely due to the powder from the gloves. Future radiographs were taken wrapped in a vinyl glove.
Case 4: A patient with a history of bilateral inguinal hernia repair and allergy to Penicillins presented to the dental clinic. He had been previously treated with latex gloves, prophy angles and rubber cups. One year prior to the writing of the article he underwent repair of a bladder perforation requiring multiple latex catheterizations. At the last dental visit, placement of a rubber dam brought on an allergic reaction including red eyes and red urticarial lesions around the mouth. Diphenhydramine was used IM. No complications during followup. Six months later, vinyl gloves were used but a latex prophy cup brought on another reaction which was remedied the same way.

The first clinical latex allergy was documented in 1979. Over the years, many additional latex allergies were documented, often in association with spina bifida and/or urogential anomalies. About 1/3 of spina bifida/myelodysplasia patients are seripositive to latex allergens. Patients requiring intermittent self catheterization should be considered high risk for latex allergy. Atopy has been reported in 45-100% of patients with a latex allergy.
Review: While most clinics are becoming more and more latex-free, it is important to take extra precautions for patients with a history of spina bifida or multiple surgeries requiring multiple latex catheterizations.

Sleep Disorder Breathing in Infants and Children: A review of the Literature

Dan Boboia 5/14/10 Lit. Review

Title: Sleep Disorder Breathing in Infants and Children: A review of the Literature
Author: Ivanhoe et al
Type of Article: Review

Purpose: To review etiology, diagnosis, and treatment of sleep disorder breathing in children and infants.

Methods: Peer-review lit. identified by Medline and a manual search conducted between 1999-2006. Key words for the search: children, sleep disorder, snoring, and obstructive sleep apnea. 153 manuscripts.

Summary:
· SDB (sleep disorder breathing): upper airway compromise (partial) resulting in a reduction of oxygen reaching the lungs and vascular system; common in children: 3-12% of children snore and 1-10% of them have OSA. Presence of asthma, exposure to 2nd hand smoke, and hay fever increased the incidence of snoring.
· OSA (obstructive sleep apnea): complete obstruction

For a diagnosis of OSA:
1) All children should be screened for snoring
2) Complex, high-risk pts. should be referred to a specialist
3) Patients with cardioresp. failure cannot await elective evaluation.
4) Polysomnography is the gold standard for discriminating between snoring and OSA


A delay in treatment of SDB children may be caused by several factors and may result in serious but generally reversible problems including:
· Impaired growth
· Neurocognitive and behavioral dysfunction
· Cardiorespiratory failure

Treatment of choice: adenotonsillectomy

CPAP is an option for patients who aren’t candidates for surgery or who do not respond to surgery. Minimal information is available concerning dental treatment of these disorders.

Minimal information is available concerning dental treatment of these children.

Latex Hypersensitivity: A closer look at considerations in dentistry

Dan Boboia 5/6/10 Lit. Review

Title: Latex Hypersensitivity: A closer look at considerations in dentistry
Author: Kean et al
Type of Article: Review

Latex Hypersensitivity:
Natural latex contains 11 potential allergens. Exposure to these allergens occurs via mucous membranes, the vascular system, inhalation, and direct skin contact. Adverse rxns. Include non-allergic contact dermatitis (direct response to chemicals and additives in latex presenting as skin erythema, chapping and vesicles), delayed type I hypersensitivity rxns, and immediate type I hypersensitivity rxns. Most are irritant contact dermatitis and type IV hypersensitivity (occurs 24-96 hrs after contact and results in purities, eczema, and paules).

Populations at risk:
· Family Hx of allergy (atopy)
· Thos exposed through occupation
· Latex-fruit syndrome: cross-reaction involving IgE antibodies in fruit allergic patients (bananas, kiwi, tomatoes)
· Pts with Spina Bifida at high risk due to repeated latex exposure
· Powder free gloves have been associated with a drop in overall prevalence of type I hypersensitivity.

Box 2 lists latex containing products.

· Cross-reactivity to gutta-percha not substantiated

Management:
· Prophylactic antihistamines or corticosteroids to known risk patients
· Clarke reports 81% of latex allergic patients did not suffer adverse rxns.
· Knowledge of how to deal with issue is best approach
· Contact dermatitis and type IV allergy – topical corticosteroids
· Mild type I rxns without resp, distress – topical steroids and Benedryl 50mg QID till stops
· Severe type I with resp distress – PABC’s, activate EMS, O2, epi .01mg/kg 1:1000 or .1mg/kg 1:10000, benedryl and corticosteroids for post-op.

Appliance for chronic drooling in cerebral palsy patients

Resident: Roberts
Date: 5/7/10
Article title: Appliance for chronic drooling in cerebral palsy patients
Author: Inga, Charlie et al.
Journal: Pediatric Dentistry
Volume 23:3
Year: 2001
Discussion
The drooling appliance is very similar to an orthodontic retainer in its design and fabrication. It is an intraoral appliance with full palatal coverage that is constructed of dental acrylic with wire clasp arms and a labial bow. A movable rolling bead is placed in the posterior aspect of the appliance. The location of the place of the bead is dependent on the swallowing pattern of the child Normal tongue position during swallowing is in the midline; however patients with CP may have a deviation to one side or the other. It is critically important to place the bead so that the tongue will be able to come in contact with it and yet be positioned far back in the throat. Instructions on how to use the appliance are controversial. Some clinicians believe that the appliance should only be used when in public places where drooling is a social stigma. They believe that the patient will become resistant to the effect of the appliance. Others believe that it should be used all the time and that the bead should be manipulated as the tongue position changes. Both have been proven to be effective. One recommendation in the article was that the patient be of age and have the cognitive ability to understand the appliance and be involved with the fabrication of it by responding to verbal commands to swallow and helping to determine proper bead placement.
Assessment: Short article and did not get much into explaining why this physiologically worked.

Diagnosis and Management of Osteomyelitis

Resident: Roberts
Date: 5/7/10
Article: Diagnosis and Management of Osteomyelitis
Author: Carek, Peter et al.
Journal: American Family Physician
Volume 63, Number 12
Year: June 15, 2001
Discussion
Osteomyelitis is an inflammation of bone caused by a pyogenic organism. This infection occurs predominantly in children and is often seeded hematogenously. In adults, osteomyelitis is usually a subacute or chronic infection that develops secondary to an open injury to bone and surrounding soft tissue. The specific organism is usually associated with the childs age, or associated with trauma or a recent surgery. Staph. Aureus is associated with acute osteomyelitis. S. Aureus, Psuedomonas Aeruginosa, Serratia Marcescens and Escherichia Coli are associated with chronic osteomyelitis. Osteomyelitis is usually detected through means of clinical and radiographical evaluation and diagnosed using a histopathological and microbiological examination. Acute osteomyelitis is best managed with a four to six week course of antibiotics administered parenterally. Chronic osteomyelitis is generally treated with antibiotics and surgical debridement. In addition to antibiotics, debridement, dead-space management and stabilization of bone may be necessary.

Assessment: I was surprised the article did not mention anything about associations with bisphosphonate therapies in adults

Drooling of saliva in children with cerebral palsy- etiology, prevalence, and relation ship to salivary flow rate in an Indian population

Resident: Roberts
Date: 5/7/2010
Article title: Drooling of saliva in children with cerebral palsy- etiology, prevalence, and relation ship to salivary flow rate in an Indian population
Author: Hegde, Amitha; Pani Sharat.
Journal: Special Care Dentistry
Volume: 29(4)
Year: 2009
Background:
Drooling is the escape of excess saliva from the mouth. It is commonly seen in normal infants and usually subsides by 15-18 months of age as a consequence of physiological maturity of orofacial motor function. Some studies indicate that drooling beyond an appropriate age is due to increased salivation and decreased or ineffective swallowing. Other studies and reviews of literature show it is mainly due to a swallowing defect caused by poor neuromuscular coordination.
In this study, the prevalence of drooling, the impact of various etiological factors on it severity, and its relationship to salivary flow rate were assessed in 113 individuals (6-18 yrs old) with cerebrals palsy(74 males and 39 females). The severity of drooling was assessed by visual examination, demographics and data regarding severity and control of drooling were collected via a questionnaire. Data concerning the type of CP and medications the patient was on was obtained by medical records
Results:
48.7% of patients reported drooling. 17.7% reported severe drooling. Individuals with athetosis had the least severe amount of drooling. There was a significant relationship between the ability to close the mouth and the severity of drooling. The severity of drooling was reduced with age. There was no significant difference in the mean salivary flow rate of those children who drooled and those who did not. No signicant difference between drooling in children with and without intellectual disability was found.
Conclusion:
The incidence of drooling among CP patients was almost 50%. Drooling of saliva may regress spontaneously with age, but speech therapy and the ability to close the mouth has the greatest effect against drooling.

Assessment: This would be one of those facts that would be fun and helpful to pull out of your back pocket when you need at the right time.