Dental Management of patients receiving anticoagulation or antiplatelet treatment

Resident: Roberts

Date: 3/2/2011

Article title: Dental Management of patients receiving anticoagulation or antiplatelet treatment

Authors: Pototski, M and Amenabar, Jose

Journal: Journal of Oral Science

Volume: 49

Number: 4 pages: 253-258

Year: 2007

Platelets are the major player in arterial thrombosis and therefore are attractive targets in the prevention and treatment of cardiovascular deseases such as myocardial infarction, cerebral ischemia, and peripheral arterial insufficiency. Acetylsalicylic acid(aspirin) and Warfarin are the standard drugs for the prevention of vascular diseases.

Bleeding times historically have been measured by Prothrombin time (PT) and partial thromboplastin time (PTT). However, in 1983 the World Health Organization introduced the International Normalized Ratio (INR patients PT/ mean normal PT) to standardize values globally.

A patient with a normal coagulation profile would have an INR of 1.0. It is recommended that a patient undergoing invaisive treament should have a PT within 1.5 to 2.0 times the normal INR which corresponds to a value of 1.5 to 2.0.

It has been suggested that complication from invasive procedures with patients on anti-platelet/anti-coagulation therpay arrise from the complication of four criteria: 1. bleeding time continues beyond 12 hours, 2. the bleeding causes the patient to call or return to the clinic for continued care, 3. development of a large hematoma or ecchymosis occurs within the soft tissues, 4. the patient requires a blood transufusion.

Patients undergoing anti-platelet therapy may have bleeding times twice that of what they normally would. However, this may still be acceptable for most dental procedures. A study investigating stopping or continuing low dose ASA prior to dental extractions was done by Ardekian. Thirty nine patients taking 100mg daily were studied. 19 cont’d as normal before the extractions and 20 stopped taking ASA 7 days prior to treatment. The mean bleeding time was longer in patients who continued ASA compared to those who stopped. However, none of the patients had a bleeding time outside of normal limits.

Wahl studied the impact of patients who stop or continue anti-coagulation therapy prior to a variety of dental procedures. 542 documented cases involving 493 patients were reviewed. He reported that four patients experienced fatal thromboembolic events(2 cerebral thromboses, 1 myocardial infarction, 1 embolus - type not specified). One patient experienced two non-fatal throbomembolic complications and the majority of patients had not adverse effects. The incidence of adverse effects was 1%. In another study, he reviewed 2400 dental procedures that were undergone by 950 patients who continued their regime prior to treatment. Only 12 patients (less than1.3%) experienced bleeding uncontrolled by local measures and none were reported to have serious side effects or harm from the incidence. Of the 12 patients seven had higher than recommended INR values.

Conclusion: Bleeding complications while inconvenient, do not carry the same risks as thromboembolic complications. Patients are more at risk of permanent disability or death if they stop antiplatelet or anticoagulation therpay prior to treatment. There is no single report of uncontrollable bleeding when dental procedures have been carried out without stopping treatment before hand. In contrast serious fatalities have been noted by those that have stopped by to recieving treatment. Research has concluded that minor dental surgical procedures can be done safely with an INR within the range of 2.0 - 4.0 and anything above should be dealt with prior to treatment. Ideas for management include: scaling one quad at a time, using local anesthetic with epinephrine as a hemostatic agent when doing extractions, avoid regional nerve blocks when infiltrations are possible. After extractions pack the socket with absorbable dressing and suture the site with resorbable sutures, and allow the patient to apply pressure to gauze over the extractions site.

Assessment: Great article. Because this research was published fairly recently, more research is needed. However, this may be a mindset adopted within the dental community once more research has been published.

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Bleaching of Nonvital Teeth, A Clinically Relevant Literature Review

Author(s): Zimmerli et al.

Journal: Schweiz Monatsschr Zahnmed?

Year. Volume (number). Page #’s: 2010. 120(4). 306-313.

Major topic: Bleaching

Overview of method of research: Literature Review

Purpose:
Review current literature presenting the etiology if tooth discolorations, different treatment techniques, their degrees of success and risks of bleaching procedures.

Materials & Methods:
A PubMed literature search was performed and predominantly articles from the last 10 years were analyzed.

Findings:
1. Etiology of Intrinsic Discolorations
A. Pre-eruptive causes: medications (tetracycline), metabolism (fluorosis), genetics (AI, hyperbilirubinaemia), trauma.
B. Post-eruptive causes: pulpal necrosis, intrapulpal hemorrhage, residual pulp tissue after endo treatment, endo materials, filling materials, root resorption, aging process.
a. hemorrhage after trauma is the most common cause as blood enters dental tubules and decomposes into hemosiderin, hemine, hematin and hematoidin. Pulpal necrosis can also produce these products.
b. protein degradation products
c. calcification of the pulp (often follows trauma, erosion, abrasion or other iatrogenic irritations)
d. combinations of irrigants such as NaOCl and chlorhexadine or Biopure MTAD
e. CaOH, MTA and sealers

2. Mechanism of bleaching
A. Long chain organic pigment molecules are oxidized into smaller, lighter C, water and oxygen
B. Some manufacturers also recommend heat or light, but these can lead to root resorption

3. Bleaching Agents: in Switzerland products >6% hydrogen peroxide (or equivalent) for professional use
A. hydrogen peroxide- used with caution in high concentration (>30%) to avoid root resorption
B. sodium perborate- when water is added H2O2 is released, same bleaching effect
C. sodium percarbonate- mixed with water to produce H2O2, but clinical studies still lacking
D. carbamide peroxide- organic cmpd containing H2O2 and urea, equal effects as H2O2

4. Indications for Internal Bleaching
A. Discolorations due to metal ions (silver pins or alloys) not reliably bleachable
B. Symptoms free endodontically treated tooth with a sealed root canal filling (base material)
a. perforation restorations must also be sealed as MTA exhibits reduced marginal seal when in contact with bleaching agents
C. Sufficient coronal restorations

5. Root Resorptions
A. When only thin dentinal walls remain, it is recommended that only low concentrations of bleaching agent are used in order to prevent the material from entering the periodontal space causing inflammation and subsequent root resorption
B. Incidence reported between 1-13%, the exact etiology has not been explained
C. Heat is generally not recommended as increases in root resorption are seen.

6. Recurrence
A. Recurrence rates are relatively high
B. One study reported that after a 5 year observation period, 75% of dentists judged a case successful while 98% of patients were satisfied.

7. Technique: Pre and post treatment photos should be documented.
A. Walking Bleach technique
a. The access made and 2-3mm subginival filling material is removed and sealed. Sodium perborate is mixed with water or H2O2 and inserted into the access as a paste and a temporary closure material is applied. Cavit and Coltosol have been shown to work the best. Optimal timing for re-eval has been shown to be 33 hours for young patients and 18 hours for older patients. Sometimes CaOH is recommended to counteract the increased permeability of the dentin and raise the low pH, but the authors find little clinical relevance for this as dentin has a great buffering capacity. Ascorbic acid solution can promote normal adhesive bond strengths prior to restoration placement.
b. H2O2 has been shown to have detrimental effects on the microhardness of enamel and dentin whereas sodium perborate has not.
B. Inside/Outside Bleaching
a. One advantage is that low concentration of bleaching material is required. A vacuum formed splint is fabricated on a model where the adjacent teeth have been slightly ground down to ensure a tight fit and to prevent accidental exposure to bleaching agent. 10% carbamide peroxide is placed once the tooth has been accessed and the splint is worn at night and the patient is to return for re-eval every 2-3 days. One week later a definitive restoration is to be placed.
b. One obvious downside to this treatment is patient compliance as well as lack of bacterial control during bleaching. Although initial results may be better in the first few days, after 6 months and rehydration of the tooth the results are similar to those of the walking bleach technique.
C. In-Office Bleaching
a. This method is well known, but offers the least predictable long-term results as much of the color change is due from the dehydration of the teeth with the rubber dam.
b. Rubber dam is placed, 30% H2O2 is placed onto and in the tooth for 15-20 minute periods which can be repeated as necessary. The definitive access closure should be performed at a subsequent appointment as a large amount of H remains in the cavity

Key points/Summary:
There is relatively low risk with bleaching endodontically treated teeth and it is a valuable option when appropriately indicated. However, cervical root resorptions can occur more frequently with higher concentrations of bleaching agent, past trauma and the application of heat. It is also important to notify patients of the relatively high recurrence rate and possible risks involved.

Assessment of Article: This was a great review of bleaching nonvital teeth and very applicable clinically. I had heard of some of these techniques, but it was great to read the overviews and compare them side by side.

Over the Counter Whitening Agents: A Concise Review 2/23/11

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title:Over the Counter Whitening Agents: A Concise Review
Author(s): Flavio Demarco PhD, et al
Journal: Brazilian Oral Research
Year. Volume (number). Page #’s: 2009. vol 3 NO 1 64-70
Major topic: Whitening agents
Minor topic(s): OTC agents, side effects
Main Purpose: To evaluate and discuss the current knowledge concerning efficacy, mechanism of action, and legislation of OTC tooth bleaching agents
Overview of method of research: Review

Findings:
The big buzz word in dentistry is ‘esthetic dentistry’. Tooth discoloration is of course, not esthetic. Tooth discoloration can be caused by either intrinsic (stains in enamel/dentin relative to their properties) or extrinsic stains from food, drink, etc. Everything from microabrasion to bleaching can be used to try to remove such stains. Dentist supervised home-use bleaching custom trays is the most common procedure dispensed by dentists. Usually, this involved custom made suck down trays that are filled with 10% carbamide peroxide and worn at night for +/- 2 weeks. While 10% is the most common concentration used (and the only conc. Accepted by the ADA), conc. Of 15 and 20% can also be used. Most adverse affects reported for at-home bleaching systems are tooth sensitivity and gingival irritation, which both disappear when the agent is stopped or removed with sodium fl.

In addition to bleaching that is overseen by dental professionals, there are many OTC tooth whitening systems available on the market today. The OTC systems may also cause side effects, and may not be as efficacious as the systems offered by dental professionals. For whitening to be considered clinically significant it must have a value of 4 units gained on the vita shade guide.

Whitening Tooth Pastes
More than 50% of the products rarely contain CP, HP, or any kind of bleaching agent. In actuality, the paste is filled with abrasives that remove superficial stains on the teeth instead of ‘whitening’ them. Active components include enzymes that break down the organic molecules of the biofilm. These pastes can be dangerous because of the high amount of abrasiveness, which could lead to excessive wear of enamel and dentin. The whitening is not clinically significant.

Rinses
Generally these contain a low con. Of HP, 1.5%. Studies have shown that systems utilizing trays are much more effective than rinses. The whitening observed with rinses, if any, were not clinically significant.

Whitening Floss and Tooth brushes
Allegedly, whitening floss can remove stains at the gingival, subgingival, and interproximal areas. As with the pastes, the floss has a high amount of abrasives in it to remove staining, while whiteneing is not clinically significant. With regards to tooth brushes, studies have shown that power tooth brushes showed a better ability to maintain whitening as opposed to traditional brushes.

Chewing Gum
Gum with sodium hexametaphosphate 4-7.5% has been introduced, claiming to do the job. However in clinical trials, when compared with gums containing nicotine, the nicotine gum did a better job of whitening extrinsic stains.

Paint on Gels
Gels or varnishes that have HP 6% or CP 18% can be brushed onto the teeth. Again, when compared to the tray systems, the paints/gels did not do a good job, however it was seen that HP worked better than CP.

OTC tray activated by light
New product that is light activated. NO active ingredient listed. Needs more research/info.

Whitening strips
Filled with HP 5-15%. Worn for 5-60 min at a time for 28 days to give the best result. Can get clinically significant results with less side effects than the trays. Because strips are effective and relatively cheap, ranging in cost from $2-$35, most people are using them as opposed to going to a tooth whitening center where the cost may be $400.

Safety Guidelines
In 2005, 2 billion dollars was spent on OTC whitening agents. The pharmaceutical companies invested twice as much in marketing as they did in research... so buyer beware. It is recommended that bleaching only be done in children age 15 and older. In Europe, .1-6% HP is only considered safe when administered under a professionals care. The ADA says that OTC agents are safe, but should be used under a professionals supervision.

In relation to carcinogenesis, high conc of HP may act as a promoter or oral lesions together with other agents such as alcohol and tobacco, but low conc of CP are safe. Never drink any peroxide agents.

Addiction to whitening agents is common. Many people over self medicate. The ‘bleachorexics’ or ‘whitening junkies’ repeatedly use the agents without the care of a professional, and often cause themselves harm. Something to be aware of.

Key points/Summary:
1. Whitening pastes, floss, and brushes remove superficial stains, and are not bleaching agents.
2. Paint on gels and rinses have low levels of bleaching agents and do not produce clinically significant results.
3. Whitening strips can produce an effect similar to 10% CP in a tray, however more long term research is needed.
4. Legislation varies from country to country. Clinicians need to be aware of available products, and that abusive self medication is possible and can cause harmful effects.
5. More research is needed.

Assessment of Article:
Very thorough review. It’s always tough to summarize a summary. Excellent info for boards, especially since the last few years there have been a lot of questions on bleaching.

Clinical Management of Regional Odontodysplasia

Resident: Adam J. Bottrill
Date: 16FEB11
Region: Providence
Article title: Clinical Management of Regional Odontodysplasia
Author(s): Cahuana, Abel PhD, MD, DDS
Journal: Pediatric Dentistry
Page #s: 37-39
Vol:No Date: 27:1 2005
Major topic: Odontodysplasia,
Minor topic(s): Ghost Teeth, Tooth Autotransplantation
Type of Article: Case Studies and Discussion

Main Purpose: The purpose of this study was to describe the characteristics and clinical management of 2 patients diagnosed with ROD at the Pediatric Dentistry Service at the Hospital Sant Joan de Deu, Barcelona, Spain.

Key points in the article discussion:

I. General

A. Regional Odontodysplasia (ROD) is a relatively rare localized developmental anomaly of the dental tissue.
B. 1989: Females>Males, no race association
1. Etiological factors: local circulatory disorders, viral infections, pharmacotherapy during pregnancy, facial asymmetry, local trauma, metabolic disturbances, somatic and neural mutations, sundromal involvement.
2. TRUE ETIOLOGY unknown.
C. Clinical criteria:
1. Maxialla>Mandible
2. Usually unilateral, rarely crosses midline
3. Small, brosn, grooved, hypoplastic teeth
4. Eruption failure
5. Abscesses or fistulae in the absence of caries
6. Radiographic lack of contrast between enamel and dentin. Overall less radiodense.
7. "Ghost Teeth"
8. Large pulp chambers with stones or denticles
9. Histological characteristics
10. Bone not affected

II. Case #1:

A. Hx:
1. 5yo boy
2. Pain and inflammation Rt Maxilla.
3. Hx of infections in the area.
B. Exam:
1. Gingival swelling upper Rt maxilla
2. Abnormal morphology, irregular surface and yellow/brown color of teeth in the area
3. Incisors fractured to root level.
4. Tooth morphology otherwise normal
5. "Ghostly appearance"
C. Tx:
1. Sub-G scaling, 3-mo recare
2. Pt returned two months later for follow up. Swelling had returned.
3. Affected primary teeth extracted, acrylic appliance fabricated.
4. Autotransplantation at age 10 due to dentoalveolar discrepancy
5. Current plan is to maintain the autotransplanted teeth until orthodontic and prosthodontic rehabilitation possible.

III. Case #2

A. Hx
1. 3 yo girl presented for abscess in upper left.
B. Exam:
1. Upper left abnormal tooth morphology and abscess of caries.
2. Gingiva swollen and tender on palpation.
3. Ghost teeth.
C. Tx:
1. OHI
2. Acrylic appliance fabricated due to failed eruption.
3. At age 7, waiting for future treatment plans.

IV. Conclusions:

A. Neither case described can be related to any current etiological factors.
B. ROD cases require continuous and multidiscplinary approach.


Assessment of article: Case reports... pretty straight forward. No earth-shattering conclusions.

AAPD Policy Statement on the Use of Dental Bleaching

Resident: Swan
Article Title: Policy on the Use of Dental Bleaching for Child and Adolescent Patients
Author: AAPD Council of Clinical Affairs
Journal: AAPD Guidebook
Volume (Number): Revised 2009
Major Topic: Dental Bleaching
Type of Article: AAPD Guideline
Main Purpose: To help professionals make informed decisions about bleaching in both the primary and permanent dentitions.
Method: Medline/Pubmed systematic literature search of last 10 years regarding bleaching in patients up to age 18. 62 articles met the criteria.
Findings: Bleaching is becoming more and more popular and parents/patients are inquiring more and more about it. Clinical indications for external or internal bleaching include discoloration from trauma, irregularities in permanent tooth enamel due to infection or injury to the primary predecessor, or intrinsic discoloration/staining (tetracycline, fluorosis). Bleaching is not recommended during the mixed dentition stage because it would result in a mismatched appearance once the permanent dentition is complete.
Two options available, professional or at home. Advantages of professional, in-office bleaching include
1. initial professional evaluation to determine the cause of the discoloration and discuss clinical concerns (other existing restorations, side effects, etc) 2. Professional control (accelerant use) and soft tissue protection 3. Patient compliance 4. Rapid results 5. Stability of results. In office bleaching formulations range from 10% to 38 % carbamide peroxide.
At-home bleaching options include bleaching gels, whitening strips, and brush on pastes. Their main advantages are convenience and lower cost.
The more common side effects associated with bleaching vital teeth include tooth sensitivity and soft tissue irritation. Both are temporary and resolve when bleaching is discontinued. Another documented side effect is increased marginal microleakage of existing restorations. When internally bleaching nonvital teeth, the most common side effect is external root resorption due to the formation of hydroxyl free radicals. Use the lowest effective concentration.

Key Points/Summary:
AAPD Policy Statement:
1. AAPD recommends judicious use of bleaching for vital/non-vital teeth
2. patients should consult their dentists for appropriate timing of and methods for whitening within a comprehensive treatment plan
3. side effects need to be considered
4. further research needed regarding children.
The AAPD discourages full arch bleaching in the mixed dentition.

Color and Surface Temperature Variation During Bleaching in Human Devitalized Primary Teeth: An In vitro Study

Resident: Roberts

Date: 2/23/11

Article title: Color and Surface Temperature Variation During Bleaching in Human Devitalized Primary Teeth: An In vitro Study

Author: Gontijo, Isa

Journal: Journal of Dentistry for Children

Volume: 75:3

Year: 2008

Purpose: The purpose of this article was to study two different whitening techniques in primary teeth. An assessment regarding color and temperature surface variation, during dental bleaching using different catalytic sources would be performed.

Method: Twenty one human upper central deciduous incisors were used for the study. They were darkened in human blood for a period of 21 days( didn’t specify where they got the blood!), they were randomly distributed into 2 groups according to bleaching source of activation: (1) a diode laser group, (2) a halogen lamp group. The bleaching process was performed according to manufacturers guidelines. The color was assessed by spectrophotometry and the VITA scale before and immediately after tooth whitening. A thermographic camera was used to register the rise in temperature and the radicular surface during bleaching.

Results/conclusion; There was no significant difference for temperature variation. The of a diode laser and halogen lamp both promoted whitening in devitalized primary teeth in vitro. As a catalytic source of energy the diode laser, with the applied parameters, promoted a smaller temperature increase compared to the halogen lam during the bleaching procedure on non vital primary teeth.

Assessment: Results were vague and did not give alot of practical application to clinical dentistry.

Tooth Whitening in Children and Adolescents: A Literature Review

Meghan Sullivan Walsh February 23, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Tooth Whitening in Children and Adolescents: A Literature Review

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Tooth Whitening in Children and Adolescents: A Literature Review

Authors: Sean S. Lee, DDS; Wu, Zhang, MD; D. Harvey Lee, DDS, MPH; Yiming Li, DDS, MSD, PhD

Journal: Pediatric Dentistry

Volume (number), Year, Page #’s; 27:5, 2005, pages 362-368

Major Topic: To summarize the findings of the use of peroxide based tooth whitening agents in children and adolescents.

Overview of Method of Research: Literature review on child and adolescent tooth whitening, its side effects, usage trends, safety concerns and carcinogenesis. Recommendations for whitening usage is also mentioned.

Findings:

Parents and children are reporting that their tooth discoloration is “bringing negative attention.” In a 2004 study, 32% of children and 19% of these children’s parents were dissatisfied with their tooth color while only 9% of dentists felt these subjects had an unsatisfactory color. In one study, many children, some as young as ten, reported wearing tooth whitening strips on their way to school in the morning. A survey of American schools are reporting that 92% teach night guard bleaching.

Primary teeth whitening - Very few studies have been performed on whitening safety for children, particularly primary teeth, mostly due to ethical reasons. While the ADA has approved many teeth whiteners there is no specific indication or description of the use of these materials for children. It is unclear if the thinner enamel and dentin as well as the larger pulps will be effected more or less negatively. Children’s teeth are easier to bleach due to enamel permeability however the pulps may receive more exposure to peroxide.

Effects on micro hardness: In vitro studies are showing that dentin may become demineralized and a decrease in micro hardness. However other investigations are showing no significant difference between teeth exposed to bleaching and those with no exposure.

Carconogenicity: There is inadequate evidence regarding the carcinogenicity of hydrogen peroxide in humans.

Suggested approaches for pediatric tooth whitening:

Tooth bleaching should be done only with strict supervision of the dentist and parents. Due to compliance issues, younger children should not use at home bleaching. At home whitening treatments should be delayed to patients until the age of 14 or 15. A signed document and informed consent for treatment should be considered. The patient’s health history, risks and benefits should be discussed and carefully evaluated. A lower concentration of peroxide or carbamide peroxide should be used with a custom fabricated tray. Parents should be reminded of the intense sensitivity which can occur in the first 24 hours. Considering fluoride treatments after bleaching should also be discussed.

Key Points: Summary: The authors state that there are no indications for primary teeth whitening. The AAPD encourages the judicious use of bleaching in adolescent patients and discourages full-arch cosmetic bleaching for patients with mixed dentition. The authors also discussed having the FDA ban selling OTC bleaching products to minors. Adolescents are showing signs of misuse and overuse of these products and there are no extended use studies of these products on children.

Assessment of the Article: Just the title alone of this article made me upset. I feel we should really take a closer look at our children and adolescents as well as their parents who are requesting bleaching products. I have a big concern with the influence our society and parents are imposing on children to look a certain way in order to feel adequate. Tooth whitening has a role in our profession and can make a huge impact on a someone’s self esteem and our treatment. However it upsets me that even our pediatric and young adolescent patients are already feeling this pressure to look a certain way in order to feel accepted.

02/23/2011 Tooth Bleaching-A Critical Review of the Biological Aspects

Resident: J. Hencler
Date: 02/23/2011

Article title: Tooth Bleaching-A Critical Review of the Biological Aspects
Author: Duhl, Pallesen
Journal: Crit Rev Oral Biol Med 14(4):292-304 (2003)
Type of Article: Review

Introduction:
Tooth discoloration is classifies as intrinsic, extrinsic, or a combination of both. Intrinsic staining is caused by incorporation of chromatogenic material into the dentin and enamel during odontogenesis or after eruption. Exposure of high levels of fluoride, tetracycline, developmental disordered, and trauma to the developing tooth may result in pre-eruptive staining. After eruption, aging, pulp necrosis, and trauma are the main causes of intrinsic staining. Coffee, tea, red wine, carrots, oranges, and tobacco cause most extrinsic staining. Tooth bleaching can be performed externally (vital tooth bleaching) and intracoronally (non-vital tooth bleaching).

Medicaments:
Hydrogen peroxide (H2O2) is the active agent in tooth bleaching. It may be applied directly, or produced in a chemical rxn from sodium perborate or carbamide peroxide. H2O2 acts as a strong oxidizing agent through the formation of free radicals, reactive O2 molecules and H2O2 anions. These reactive molecules attack the long-chained, dark-colored chromophore molecules and split them into smaller, less colored and more diffusible molecules.

Intacoronal Non-vital Tooth Bleaching:
The medicament is placed in the pulp chamber, sealed, left for 3-7 days, and is replaced regularly until acceptable bleaching is achieved. Cervical root resorption is an inflammatory-mediated external resorption of the root, which may be seen after trauma and following intacoronal bleaching and has been reported. Intra-coronal bleaching requires healthy periodontal tissues and RCT that achieves proper obturation and a completely sealed canal orifice to prevent bleaching agent from reaching the periapical tissues.

External Vital Tooth Bleaching:
Four different approaches include 1) dentist-administered bleaching: a high concentration medicament often supplemented with a heat source 2) dentist-supervised bleaching: by means of tray delivered high concentrated medicament for 30 mins to 2 hrs while patient in dental office 3) dentist-provided bleaching: AKA at- home bleaching with custom made tray 4) over the counter products.

Side Effects:
Tooth sensitivity: most common side effect of external tooth bleaching. The mechanisms responsible have not yet been fully established. In vitro studies have shown that peroxide penetrated enamel and dentin and entered the pulp chamber. Histological evaluation revealed mild inflammatory changes.
Mucosal irritation: High concentration of H2O2 is caustic to mucous membranes and may cause burns and bleaching of the gingival.
Alteration of the enamel surface: The enamel surface exposed to bleaching agents underwent slight morphologic changes including loss of the aprismatic enamel layer and changes in the inorganic composition.
Effects on restorations: lab studies report increased mercury release from amalgams exposed to some bleaching medicaments. Also, the bond strength b/t enamel and resin-based fillings was reduced in the first 24hrs of bleaching.

Genotoxicity and Carcinogenicity:
H2O2 has been shown to have a weak local carcinogenic-inducing potential. The mechanism is unclear, but the genotoxic action cannot be excluded, since free radicals formed from H2O2 are capable of attaching DNA.

Summary of conclusions:
Generally, bleaching is safe and its use is widespread. The practitioner should be selective and provide professional bleaching to the patient in which this treatment is clinically justified.

Assessment of article: Good in-depth review of tooth bleaching.

Effectiveness and Safety of Tooth Bleaching in Teenagers

Resident: Cho
Author(s): Donly et al.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2005. 27, 298-302
Major topic: Tooth bleaching
Type of Article: Scientific Article

Main Purpose: To compare the efficacy and tolerability of oral hard and soft tissues exposed to tooth whitening in teens following the use of two different tooth bleaching methods.

Methods:
Controlled, randomized, 4-week clinical trial compared two different bleaching systems and regimens:
1. 10% hydrogen peroxide strip system (Crest Whitestrips Premium): 30 minutes twice daily
2. 10% carbamide peroxide tray system (Opalescence) used overnight

The volunteer study population was fifty-seven children (aged 12- to 17- years old) who wished to whiten their teeth. Subjects had to have all permanent anterior teeth erupted and the teeth were required to match a Vita shade guide score of A2 or darker. At baseline, subjects were assigned to either a strip or tray treatment. 45 children were assigned the strip and 12 subjects were assigned the tray-based system.

At baseline, systematic oral hard and soft tissue exam was completed and photographs were taken. Those findings were also taken every appointment thereafter. All subjects, at each appointment, were asked to describe any abnormal feeling or discomfort they experienced.

Findings:
Both treatment groups showed significant tooth-whitening improvement relative to baseline. Clinical response was similar for the 2 groups. Both treatment regimens were generally well tolerated. Minor tooth sensitivity and oral irritation were the most common complaints: 27% (12 patients) of strip group and 42% (5 patients) of tray group complained of these.

Key points/Summary:
1. 10% hydrogen peroxide strip system and 10% carbamide peroxide tray system were equally effective at bleaching teeth over a 4-week period, with both systems producing significant whitening.
2. Each system was well tolerated and most of the reported adverse effects for both products were mild.

Assessment of Article: Did not like that they assigned 3 times more people to the strip group than the tray group. Not an even assessment since numbers between the groups are different.

Resident: Swan
Article Title: Aberrant Root Formation: Review of Root Genesis and Three Case Reports
Author: Saini et al.
Journal: Pediatric Dentistry
Volume (Number): 26:3 (2004)
Major Topic: Root Development/Tooth Eruption
Type of Article: Case Report
Main Purpose: Present 3 cases of unerupted teeth with root dysmorphology and discuss root development and tooth eruption briefly.
Findings:
Root Genesis: Root formation follows the completion of the crown formation, resulting from interactions between dental epithelial and mesenchymal tissues. Root formation can be affected by chemo and radiation therapy, trauma, and hereditary factors (dentin dysplasia and others).
-- After crown formation, inner and outer epithelial cells (enamel organ) join together at the cervical end to form Hertwig’s Epithelial root sheath. IEE directs transformation of peripheral dental papilla cells into odontoblasts. The odontoblasts proliferate and secrete predentin. When the predentin mineralizes, the root sheath cells uncouple from the dentinal surface and move a distance to form the epithelial rests of Malassez. This creates holes in the root sheath. Mesenchymal cells of the dental follicle migrate through these holes to contact the dentinal surface, transforming into cementoblasts. There you have cementum.
Eruption: Eruption is mediated largely by the dental follicle (thin, dense ectomesenchymal tissue surrounding the crown). After root formation begins, the dental follicle lays down an eruption pathway for the tooth to follow. The follicle has specialized cells that can propagate selective bone turnover (resorption occlusally and apposition apically to the developing tooth). As the tooth moves coronally, more root growth occurs, filling the space passively. Every tooth has a specific time during which eruption is capable. If this eruption pathway is compromised during this time, ankylosis may occur.
Case 1: 14 yo f presents with a retained carious/nonrestorable max. right primary second molar and an impacted maxillary right second premolar with completed crown formation. The tooth was located close to the sinus, showed no pulpal obliteration or internal resorption, and no root formation. No history of trauma or significant medical history, and the other 3 premolars had erupted with complete root formation. At one year follow up, no root formation was noted and the pt was advised to have a fixed s.m. placed. She didn’t. 2 years later, root trunk had begun to form, but the tooth hadn’t erupted an farther. At this time the maxillary first molar was tipped and in contact with the first permanent premolar. The authors postulate that this premolar either formed its crown completely with subsequent delay of root genesis, or that possibly this was a supernumerary tooth and the normal series 2nd premolar never formed. (Supernum. Premolars often have severely delayed root formation.) The authors concluded in hindsight that the premolar should have been extracted with subsequent s.m.
Case 2: 30 yo m with similar situation as case 1—impacted maxillary right second premolar. No sig med history or trauma. X-ray showed the crown to be undergoing resorption. The mesially tipped first permanent molar was in contact with the first premolar. The impacted crown was palpable clinically near the vestibule as a bony hard swelling. These teeth usually undergo replacement resorption and become ankylosed (dental and osseous structures become difficult to distinguish) Due to the resorptive stage and age of the patient ext was not recommended.
Interestingly, evidence supports the eruption of rootless teeth. This means that unerupted teeth with no roots can still have an intact follicle/eruption pathway mechanism.
Case 3: 14 yo f complained of a broken filling in a mandibular 1st permanent molar. Examination revealed multiple missing premolars and a retained, impacted primary second molar. Extraction was not recommended as it already showed signs of internal resorption. Some may argue that proximity to the sinus floor might have inhibited root formation, but root formation is not an active growth process in an apical direction. Rootless teeth are seen in dentin dysplasia, but you should see other things with this condition: pulp obliteration, normal eruption, apical radiolucencies, early exfoliation.
Key Points/Summary: We don’t know the exact mechanism behind tooth eruption and root formation, but we do know that the enamel organ and dental follicle play a critical role. If all the steps don’t synchronize, eruption complications can result. In cases like this it’s impossible to determine the exact cause of their failed eruption.
Assessment of Article: Good to review this information. The only “clinical” help I take from the article is the ability to amaze and confuse parents when they ask about their kid’s unerupted teeth.

The Shear Bond Strength of Acetone and Ethanol-based Bonding Agents to Bleached Teeth

Resident: Adam J. Bottrill
Date: 16FEB11
Region: Providence
Article title: The Shear Bond Strength of Acetone and Ethanol-based Bonding Agents to Bleached Teeth
Author(s): Montalvan, Ericka DMD
Journal: Pediatric Dentistry
Page #s: 531-536
Vol:No Date: 28:6 2006
Major topic: In-office bleaching, bonding agents
Minor topic(s): None
Type of Article: In vitro randomized study.

Main Purpose: The purpose of this in vitro study was to evaluate the: (1) shear bond strenth (SBS) of acetone and ethanol-based bonding agents to composite resin 24 hours after being bleached with 35% hydrogen peroxide; and (2) interface morphology and mode of fracture (IMMF) between composite resin and enamel.

Key points in the article discussion:

I. General

A. Mechanisms of action in hydrogen peroxide and carbomide peroxide bleaching agents are poorly understood.
1. It is thought that MAYBE the H2O2 moves through tooth denaturing proteins which may increase the movement of ions (and stain?) through the tooth.
B. The amount of whitening depends on the concentration and time of application of these substances.
C. Enamel has been described as showing increased porosity and increased formation of surface precipitate that may decrease the bond strength of composite to enamel after bleaching.
D. Some suggest that waiting a few weeks after bleaching MAY reduce the effects on bond strength.
E. The reduction of bond strength MAY also be due to the presence of residual oxygen on resin infiltration and polimerization.

II. Methods:

A. 40 extracted teeth randomely assigned to 4 groups
1. 35% H2O2+acetone
2. H2O2+ethanol
3. acetone
4. ethanol
B. All teeth acid etched, bonding agent, resin stub, stored in saline fof 24hrs.
C. SBS determined, SEM used for IMMF eval.

III. Results:

A. SBS significantly lower in bleached vs unbleached teeth.
B. SBS did not sig vary between acetone vs ethanol based.
C. Bleaching did not interfere with adhesive treatment.
D. IMMF showed continuous interface between resin and enamel of unbleached teeth.
E. IMMF showed "sparse" interface between the resin and enamel of bleached teeth.

IV. Conclusions:

A. Morphological changes in human tooth enamel, 24hr after bleaching, were associated with reduction in the SBS of adhesives.
B. Contrary to some suggestions ethanol produced no better results than acetone.
C. Should continue to study other methods of whitening (toothpaste etc...)



Assessment of article: Weaknesses were substantial: unknown history of extracted teeth, cannot readily generalize this in vitro study to clinical application (saline storage etc...). I haven't figured out whether I think the weaknesses of this study outweigh the benefits.

A Controlled Study of Risk Factors for Enamel Hypoplasia in the Permanent Dentition.

Department of Pediatric Dentistry
Resident’s Name: Jessica Wilson

Article title: A Controlled Study of Risk Factors for Enamel Hypoplasia in the Permanent Dentition.

Author(s): Ford et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2009. 31(5). 382-388.

Major topic: Enamel Hypoplasia

Overview of method of research: Scientific Article

Background:
EH is thought to be caused by disruptions of enamel formation in the earlier stages of amelogenesis while EO occurs during the later stages. Medical conditions such as cystic fibrosis and congenital cardiac or liver conditions as well as infections are thought to affect ameloblast function. Chemicals such as fluoride, lead, anticancer agents and tetracycline are also thought to be etiologic agents of DDE.

Purpose:
To investigate the acquired risk factors of enamel hypoplasia (EH) and enamel opacities (EO) in permanent dentition of healthy Australian children from a non-fluoridated community.

Methods:
The population of children used was from one of the lowest socioeconomic districts in the state. 1,329 schoolchildren were examined by four calibrated pediatric dentists. The teeth were brushed, air-dried and scored using the modified DDE index (developmental defects of enamel). The first 52 boys and 52 girls in full permanent dentition with at least one tooth showing EH formed the EH group (104 children total). A similar group with only EO formed the EO group and a third control group was comprised of 105 children with no visible enamel defects.
One examiner who was blind to the clinical exams interviewed the parents/guardians regarding the child’s familial, social, medical, dental and fluoride histories and SES was evaluated by parental occupation and family income and the data was analyzed.

Findings:
Low SES, respiratory infections, exposure to cigarette smoking (especially by people other than the mother in 0-3yr olds), asthma, otitis media, UTI and chickenpox were all statistically significant for their association with EH. The combinations of chickenpox and UTI as well as chickenpox and exposure to cigarette smoking were also associated to high levels of EH.
There was less EO in children who used children’s toothpaste (300 ppm fluoride) and those who consumed optimally fluoridated water than those who did not. However, children who used adult toothpaste (1,000 ppm fluoride) from the aged 0-3yr were at a higher risk for EO.

Key points/Summary:
Children with low SES, histories of respiratory infections, exposure to cigarette smoking, asthma, otitis media, UTI, chickenpox and the use of adult toothpaste are predisposed to DDE.
Drinking optimally fluoridated water from 0-3yr can reduce the risk of DDE.

Assessment of Article:
I actually really liked this article. I liked that they evaluated EH and EO separately and since most of the permanent dentition had erupted relatively recently, there is less of a chance of caries playing a role in the defects. I thought the effect that the exposure to cigarette smoke had on the permanent dentition was very interesting. As always, further research to be done!

Hereditary Dentin Defects

Meghan Sullivan Walsh February 15, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Hereditary Dentin Defects

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Hereditary Dentin Defects

Authors: J.-W. Kim and J.P. Simmer

Journal: Journal of Dental Research

Volume (number), Year, Page #’s; 86 (5), 2007; 392-399

Major Topic: The development of the dentin extracellular matrix, phenotypes and clinical classification of dentin hereditary defects as well as recent genetic data.

Overview of Method of Research: Author’s perspective and review of hereditary defects of tooth dentin that are classified under the designations of dentinogenesis imperfecta and dentin dysplasia.

Findings:

Evolution and Development: The main evolutionary perspective of the dentin extracellular matrix is that the biomineralization of bone and dentin is built on an organic matrix. This matrix is important for proper assembly and function, but not necessarily involved with deposition of this mineral.

Classification of Inherited Dentin Defects: A classification system was conceived which will be discussed next to discriminate various patterns of dentin defects. However, now with advances in genetic findings a comprehensive etiology-based classification system will soon need to be proposed.

Summary of Shields Classification:

DGI-I : dental phenotype associated with OI. Discoloration and attrition of dentition. Pulpal obliteration. OI with DGI is usually associated with collagen-I defects, however the clinical expression and genetic etiology are complex. DGI-I phenotype has also been found in other syndromes such as Ehlers-Danlos syndrome, Goldblatt syndrome and Schimke immuno-osseous dysplasia.

DGI -II : clinical and radiographic similarities associated with DGI-I. One of the most common dominantly inherited disorders (1:8000) Defects in the DSPP gene can cause DGI-II and DD-II. Many persons with DGI-II experience significant dental attrition and loss of vertical dimension. A secondary effect of this disorder may be hearing loss.

DGI-III : Brandywine tri-racial isolate Coloration and shape of teeth are variable however multiple pulp exposures are observed in deciduous teeth. Radiographic variability. Expresses similar phenotype and genotype to DGI-II.

DD-I : clinical crowns normal in shape, form and color. Radiographically teeth have short roots with a cresent-shaped pulpal remnant parallel to CEJ in permanent dentition and total pulpal obliteration in deciduous dentition. Several DD-I patients show an autosomal dominant mode of inheritance but it is not known if it is an allelic disorder of DSPP or a mixed phenotype.

DD-II deciduous teeth appear similar to DGI-II. Permanent teeth are of normal shape, form and color however pulp cavities show a thistle tube deformity and often show pulp stones. A mutation in the DSPP signal peptide codon was identified recently in a DD-II family. Recent studies are showing that DD-II and DGI-II phenotypes are mild and severe forms of the same disease.

Because many of these classifications can show similar clinical observations they also share common genetic etiology. The dental phenotypes are commonly observed in multiple diseases which is leading to much ambiguity when classifying these defects.

Key Points: Summary: There are 27 different types of collagen and 42 types of collagen genes. The elaborate chemistry involved in the synthesis of bone and dentin lead us to a diverse etiology and diverse clinical manifestations of inherited defects. Advances in the understanding of growth factors, tooth development and cell differentiation are being identified and investigated. Genetic etiologies of syndromic and inherited dentin defects are helping with our understanding of these defects and may possibly lead to new classification systems.

Assessment of the Article: My brain hurts and I cannot possibly think of anything more to say.

01/26/2011 Amelogenesis imperfect (AI)

Resident: J. Hencler
Date: 01/26/2011

Article title: Amelogenesis imperfect (AI)
Author: Crawford, Aldred, Bloch-Zupan
Journal: Orphant Journal of Rare Diseases 2007, 2:17
Type of Article: Review

Definition and Dx:
AI represents a grp of conditions, genomic in origin which, affect the structure and clinical appearance of the enamel and may be associated with morphologic or biochemical changes elsewhere in the body. AI is a developmental condition of the dental enamel characterized by hypoplasia and/or hypomineralization that shows autosomal dominant, autosomal recessive, sex linked, and sporadic inheritance patterns. Dx involves exclusion of extrinsic environmental factors, establishment of a likely inheritance pattern, and recognition of phenotype and correlation with the dates of tooth formation to exclude a chronological developmental disturbance. The prevalence in the USA has been reported to be 1:14000. AI is a genetic deisease that exists in isolation or is associated to other symptoms in syndromes. It is either related to a single gene defect or arises from a microdeletion or chromosomal defects.

Classification:
Many classifications of AI exist today. Some are based on the phenotype and others use the phenotype as the primary discriminant and the mode of inheritance as a secondary factor in dx. Recently, it has been proposed that the mode of inheritance should be the primary mode of classification, with the phenotype as the secondary discriminant.

Clinical Description:
The enamel may be hypoplastic, hypomineralized or both. The affected teeth may be discolored, sensitive or prone to disintegration either post eruption or pre-eruption (idiopatic resorption).

X-linked:
Affects male and females differently. Males express the trait fully having only a thin layer of enamel of normal color and translucency and/or yellow/brown discoloration. The phenotype may be both hypoplasia and hypomineralization. When hypoplasia is the predominant type, there may be marked sensitivity to thermal and osmotic stimuli. Females may only have vertical ridges and grooves as a result of X-chromosome inactivation.

Autosomal Dominant:
Affects one or more individuals in each generation. May be predominantly or exclusively hypoplastic, manifested by thin enamel and spacing b/t the teeth or rough, irregular pitted enamel. Some case will show hypoplasia and hypomineralization. The most severe forms of hypomineralization result in enamel that has a cheesy consistency and is easily lost.

Autosomal Recessive:
More often encountered in certain ethnic grps where intermarriage w/in the the family may be more common. This review cited Polynesian communities.

Sporadic Cases:
May represent examples of autosomal recessive or new mutations. A condition referred to as molar-incisor hypomineralization (MIH) has become prominent and affect 1 or more of the 1st perm molars. MIH is not currently classified as AI.

AI as a syndrome:
Classifications of AI have included a variant w/ taurodontism as an intrinsic feature- AI w/ taurodontism (AIT). Hertwigs root sheath is responsible for root morphology/anatomy and differentiation of the inner dental epithelial cells to ameloblasts producing enamel protiens, and is a derivative of the enamel organ. AI’s genetic basis may affect this process to cause taurodontism.

AI in syndromes:
There are strong similarieties b/t AIT and tricho-dento-osseous (TDO) syndrome which has the additions features of curly hair and skeletal changes including bone sclerosis. One molecular study has reported that AIT and TDO are genetically distinct, wheras a later paper suggested that TDO and AI hypoplastic-hypomaturation w/ taurodontism are allelic.

Differential Dx:
Questions to consider: does anyone in the family have anything like this? Are all the teeth affected in a similar manner? Is there a chronological distribution to the appearance seen? Is ther any past medical hx which may have caused sufficient metabolic disturbances to affect enamel formation? The most common differential dx is fluorosis, chronological enamel hypoplasia (may be cause by prolonged GI issues, celiac disease, and leukemia chemotherapy). MIH may also be considered.

Genetic Counseling:
The mode of inheritance and underlying genomic changes are very important in dx of AI. Any child w/ a likely dx AI should be referred to a geneticist for dx confirmation.

Treatment:
Tx during childhood has been described as a temporary phase followed by a transitory phase. In infancy, the primary dentition id protected w/ SSCs on molars and nusmile crowns on incisors. The start of the eruption of the permanent dentition at 6yo is a difficult period. Some forms of AI present w/ hypersensitive teeth or teeth that disintegrate easy and may be very difficult to restore. AI requires removal of defective enamel and depending on AI severity may require a range of tx including composites to full coverage crowns.

Assessment:
Good review of a very detailed topic. A patient w/ AI should be treated with a multidisciplinary approach due to complicated genetic basis and depending on severity of enamel defects and age of patient.

Decoronation as an Approach to Treat Ankylosis in Growing Children

Resident: Cho
Author(s): Sigurdson, A.
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2009. 31. 123-128.
Major topic: Ankylosis, Decoronation
Type of Article: Conference Paper

Main Purpose: To present the most commonly recommended treatment options for ankylosed immature permanent anterior tooth.

Key points/Summary:
After PDL injury due to trauma, there are four possible sequelae:
1. Complete healing
2. Surface root resorption
3. Inflammatory root resorption
4. Replacement root resorption (ankylosis or ossesous replacement resorption) – surrounding bone and dentin are fused together, progressive and continuous, recommend removal of tooth within 2-3 years of diagnosis in children who are 10 years old or younger or before children experience a growth spurt. If the tooth is allowed to remain, there is a very high risk of severe infra-position.

Two main difficulties in restoring a defect caused by an ankylosed anterior tooth in the fully grown patient:
1. There is significantly less vertical bone height in the area of the tooth.
2. The difficulty of removing the existing root structure is very damaging to the remaining bone.

The following treatment options for ankylosed teeth:
1. Early extraction and esthetic replacement of the missing tooth by loose appliance or attachment to adjacent teeth.
2. Extraction followed by orthodontic space closure.
3. Surgical extraction and reimplantation – risk of re-ankylosis and root resorption
4. Surgical block movement – cortical plate, tooth, and surrounding bone are moved as a block and surgically repositioned.
5. Extraction followed by autotransplantation of a tooth.
6. Root submersion and transplant or osseous implant at later time (decoronation) – the crown is removed and the root is submerged to preserve the alveolus until it has reached full growth. It preserves the alveolar process’ width and height, less likely need for surgical alveolar ridge augmentation, vertical bone apposition is possible after the crown is removed. Placement of implants in the alveolus once the individual is fully grown have been reported to be relatively easy – there seems to be no need to remove root remnant prior to placement of the implant.

Steps of decoronation:
1. Full thickness mucoperiosteal flap
2. Crown removed at the level of the crestal border. The root surface’s coronal part is further reduced to 2mm below the marginal bone.
3. Any root filling material is removed. The canal lumen is left to fill with blood.
4. Primary soft tissue closure over the retained root is attempted.
5. The tooth’s crown can be used as a termporary replacement tooth by attaching it to adjacent tooth.

Case Study
10 year old patient had dental trauma to #9 - #9 avulsed and reimplanted 12 hours later, CaOH therapy was initiated 10 days after the injury, one year later, #9 was ankylosed and infra-positioned. It was determined patient was just beginning growth spurt, therefore, decoronation procedure recommended and carried out. Radiographic observation showed continued root resorption, alveolar bone maintained, no significant collapse of faciopalatal width. The patient and the family moved to a different state therefore could not be followed for the planned 30 months post-treatment.

Assessment of Article:
Very interesting article! Provides a new approach for treating ankylosed teeth that I had not heard of.

Effects of Midazolam on asthmatic children

Resident: Cho

Author(s): Kil et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2003. 25. 137-142.

Major topic: Oral Sedation, Asthma, Midazolam

Type of Article: Scientific Article

Main Purpose: To examine the safety and efficacy of midazolam in asthmatic pediatric patients undergoing dental treatment.

Overview of method of research:

24 children, 17 males and 7 females were selected for this study. The inclusion criteria included: children aged 1-6 years old with a diagnosis of mild-intermittent, mild-persistent, or moderate-persistent asthma in need of routine restorative work or extractions with sedation for behavior management. Subjects presented without food or fluids ingestion 4 hours prior to dental treatment.

A preoperative assessment included a modified asthma score, respiratory rate, pulse rate, and oxygen saturation. Each child was given 0.5mg/kg of midazolam orally. After 10 minutes, the child was separated from the parents and pulse oximeter monitor was affixed to the patient. Respiratory rate, pulse rate, and oxygen saturation were all monitored in 5 minute intervals throughout dental treatment. If necessary, a papoose board was used to control disruptive harmful behaviors. At the end of the dental treatment, asthma score, pulse rate, and respiratory rates were recorded. Immediately after the treatment, the dental operator assessed the sedation outcome using a behavior assessment. Oxygen saturation, pulse rate, and respiratory rates were also recorded 30 minutes after treatment.

Findings:

For all subjects except 2, oxygen saturations remained normal and consistently above 95% throughout the entire procedure. The 2 subjects had oxygen saturations that fell down to 94% at some point during treatment, however, oxygen saturation increased when the patient’s head and neck were repositioned.

All subjects had the same asthma score before and after treatment. Oxygen saturation and respiratory rates stayed relatively constant throughout treatment. The pulse rate rose continuously from 5 minutes through 15 minutes – this was not clinically significant since local anesthetic injection and initiation of treatment would increase pulse rate.

12 subjects had excellent behavior, 5 subjects had satisfactory behavior, and 7 subjects had unsatisfactory behavior. 5 patients required the use of the papoose board due to uncooperative behavior.

Key points/Summary:

1. Sedation with midazolam, when given orally at a dose of 0.5mg/kg, produces little to no adverse effects on asthmatic patients presenting with mild to moderate symptoms.

2. Most patients were treated with minimal difficulty at a dosage of 0.5mg/kg of midazolam.

3. With strict adherence to the AAPD sedation guidelines, midazolam is a safe and effective means of sedation for patients with mild to moderate asthma.

Assessment of Article: Interesting study – a greater sample size would have strengthened the study.

Dental Management of a Talon Cusp on a Primary Incisor

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center -Providence

Article title: Dental Management of a Talon Cusp on a Primary Incisor

Author(s): Yoon & Chussid.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2007. 29:1. 51-55.

Major topic: Talon Cusp Management

Overview of method of research: Case Report

Background:
The cause of the talon cusp has been suggested to be disturbances in morphodifferentiation. Radiographically, a talon cusp appears as two radiopaque lines converging from the cervical region to the incisal edge. The talon cusp is composed of normal enamel and dentin and may or may not include pulpal tissue. Different populations experience different frequency of talon cusps and range anywhere from 1-8%. Patients with orofacial digital II syndrome as well as Rubinstein-Taybi syndrome have a higher incidence of talon cusps and they have also been linked to peg laterals, supernumerary teeth, dens evaginatus, agenesis and impactions. The male to female ratio is 16:9 and talon cusps are 3 times more likely in the permanent dentition, 92% being in the maxilla. There 20 cases of talon cusps in the primary dentition have been reported in literature.

Clinical complications include:
1. Occlusal interferences
2. Problems with esthetics
3. Possible cusp fracture that leads to pulpal necrosis
4. Tongue irritation
5. Problems breastfeeding
6. Caries
7. Tooth displacement

Treatment Modalities:
1. Observation
2. Periodic reduction
3. Pulpectomies
4. Sealing of susceptible grooves/fissures
5. Resin crowns
6. Extractions

Case Report:
A 14-month-old patient presented for an initial exam. The parent reported a chief concern of “unaesthetic appearance and abnormal shape” of central maxillary incisor. Upon clinical exam, the patient demonstrated 100% overbite and a talon cusp was revealed on the lingual surface of the right central incisor displacing the tooth approximately 4mm anteriorly. The talon cusp extended half the distance from the CEJ to the incisal edge and grooves were present on both sides of the talon cusp. Although the tooth was asymptomatic, it interfered with occlusion. The authors decided to gradually reduce the size of the cusp to eliminate the occlusal interference as well as the increased risk of the anteriorly displaced incisor.
A total of 2mm of tooth structure was removed over 4 visits. These visits were spaced about 6 weeks apart to allow the deposition of tertiary dentition. 5% sodium fluoride varnish was applied to reduce sensitivity. It was estimated that approximately 3mm of dentin remained after treatment. The tooth remained asymptomatic at the one month post-op and the incisor appeared to move back into the arch without occlusal interference and 2mm overjet. The authors report the prognosis of this tooth to be guarded.

Discussion:
The rate of tertiary dentin formation is about 1.49µm/day and doesn’t begin until 19 days after an operative procedure. Other materials that may be used to protect the dentin include bonding agents and restorations (composites, compomers or resin modified glass ionomers). Although the authors chose to treat the tooth in this article, the majority of small talon cusps are asymptomatic and require no treatment.

Assessment of Article:
Good background information, but nothing too exciting.

The Role of Dentists in Diagnosing Osteogenesis Imperfecta in Patients with Dentinogenesis Imperfecta

Resident: Adam J. Bottrill
Date: 09FEB11
Region: Providence
Article title: The Role of Dentists in Diagnosing Osteogenesis Imperfecta in Patients with Dentinogenesis Imperfecta
Author(s): Teixeira, Cleonice DDS, MSc et al.
Journal: JADA
Page #s: 906-914
Vol:No Date: Vol 139, July 2008
Major topic: Osteogenesis Imperfecta, Dentinogenesis Imperfecta
Minor topic(s): Scanning Electron Microscopy
Type of Article: Case report, Analysis
Main Purpose: The purpose of this article is to describe a clinical case of diagnosis of dintinogenesis imperfecta (DI), in which a literature review combined with an analysis of dental alterations led to indications of osteogenesis imperfecta (OI).

Key points in the article discussion:

I. DI: hereditary disorder resulting in defective dentin formation in both primary and permanent teeth.

A. Types:
1. Type I: Associated with OI... dental manifestation of the underlying collagen defect
2. Type II: Most common, opalescent dentin, no associations
3. Type III: Brandywine MD association

B. Clinical: opalescent discoloration (brown, gray or yellow), bulbous crowns, roots narrower than usual, root canals can become obliterated over time. Possible early loss of enamel due to weak dentin.

II. OI: "brittle bone disease" is a genetic disorder that affects the connective tissue and is characterized by bone fragility and fractures, blue sclera, long bone deformity, lowered hearing capacity, can be related to OI.

A. 50% of OI cases reported to have some form of DI.

B. Because DI can go unnoticed, if DI is confirmed, the patient should be closely examined and OI should be considered.

III. Case Report

A. 11 mo, white female refered with CC of yellow discoloration of teeth. Normal growth and no other evidence of FH.

B. Primary dentition: yellow/brown discoloration with enamel fractures, dentin exposure began at 3yo. Severe attrition, pulpa exposures on posterior teeth.

C. Following primary teeth exfoliation, esthetics improved. Sealants placed on posterior occlusal surfaces.

D. Follow-up at age 15yo: opalescent gray discoloration. Multiple restorations needed to repair fractured enamel. Corncob shaped roots and bulbous crowns. MHx revealed multiple bone fractures (11) through arms, hands, feet, trunk during childhood. Lastly, deficient occlusion with bilateral crossbite.

E. Scanning electron microscopy (SEM) performed on an extracted 3rd molar revealed abnormal dentinal matrix.

F. Despite multiple visits with orthopedic clinics, OI had not been Dx. Dentist Dx DI associated with OI type I... verified by endocrine/orthopedic specialist.

G. By age 18, stable clinical presentation, pulpal obliteration, more distinct dental discoloration, new bone fractures.

IV. Discussion:

A. At first, the clinical and radiographic evidence supported DI type II due to lack of acssociated symptoms.

B. It was observed that the permanent teeth were less affected than primary and that she did not seem more susceptable to carious lesions than normal teeth. (possibly due to impeded progression with the irregular dentinal tubules and structure)

C. For the future, pt must be instructed on ways of avoiding bone fracture and osteoporosis.

D. Dental manifestations, though only occuring in 50% of OI, can be the most clinically evident signs of the disease.

E. Note: Obliteration of pukp chambers should alert dental professionals to the possibility of OI. Consider early endodontic intervention.

V. Conclusions:

A. Early and appropriate dental care can lead to improved control of oral disease, function and esthetics.

B. We should always consider the possibility of OI with any case of DI.

C. Detailed MH is important.

Assessment of article: I found it very valuable as a clinician. OI and DI are both diseases we should be intimately familiar with. The authors may have dug into the SEM material a little more than I liked, but the entire article was useful and relevant. It is also always nice to hear a case that was "solved" by a dentist. Goes against the stereotype that we aren't "REAL" doctors. Likey.

3-rooted Primary Mandibular Second Molars among Chinese patients

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!

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.