The effect of midazolam premedication on discharge time in pediatric

Department of Pediatric Dentistry
Resident’s Name:Murphy Program: Lutheran Medical Center - Providence
Article title:The effect of midazolam premedication on discharge time in pediatric patients undergoing general anesthesia for dental restorations
Author(s): Jason Horgesheimer, DDS, Charles Pribble, DDS, Ralph Lugo, PharmD
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2001. V 23 No 6 491-494
Major topic: Effects of midazolam on discharge time after GA
Main Purpose: To evaluate the effect of oral premed w/ midazolam on recovery times of children undergoing dental restorations under GA

Overview of method of research:
The records of 106 children were retrospectively reviewed at Primary Children’s Medical Center in Salt Lake City Utah. All patients were ASA I or II. 50 children received .5mg oral midazolam approx. 30 minutes before the procedure. 56 children did not receive any premed. All children were mask inhalation induced with either nitrous, sevoflurane, or halothane. Also, all patients were nasotracheally intubated. Things taken into account in the study were time spent in the OR, post anesthesia care in the PACU, and time spent in the same day surgical suite.

Findings:
Oral midazolam is one of the most common pre-medications used in pediatric anesthesia practices today. It effectively decreases anxiety, produces amnesia, and facilitates anesthetic induction. Theoretically, midazolam has the potential to cause post op sedation and delay recovery from GA. However there is no clear consensus about this in the literature.

In this retrospective study there was no significant difference between the groups with respect to time spent in the OR, PACU, or SDS.
Key points/Summary:
Pre-op midazolam does not delay discharge of children undergoing GA.

Assessment of Article:
Good article. Right to the point. It shows that administering oral midazolam approx 30 min prior to anesthesia induction, the child receives the maximum post op benefit of anxiolysis and amnesia while not delaying discharge.

Dental Fluorosis: Chemistry and Biology

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Dental Fluorosis: Chemistry and Biology
Author(s): T. Aoba, O. Fejerskov
Journal: Critical Review of Oral Biology and Medicine.
Year. Volume (number). Page #’s: 2002 V 13, NO 2. 155-170
Major topic: Fluorosis (FL)
Overview of method of research: THOROUGH review

Findings:
Fluoride (Fl) is the most important caries preventative agent in dentistry today. An increase in various fluoride forms and vehicles has caused an increase in mild to moderate FL in many communities. The effect of Fluoride on enamel formation that causes FL in humans is cumulative. This review article was aimed at discussing the pathogenesis of FL in relation to a putative linkage between ameloblastic activities, secreted enamel matrix proteins/multiple proteases, growing enamel crystals, and fluid composition including Ca and Fl ions.

Enamel is very sensitive to free Fl ions. Once Fl is incorporated into the enamel matrix, the ion affects subsequent mineralization process by reducing the solubility of the mineral. Numerous human and animal studies hve proven that enamel hypomineralization in teeth w/ FL is mostly due to the aberrant effects of excess Fl on the rates at which enamel matrix proteins break down, and at which the rate of the by products are withdrawn from the maturing enamel. Any interference with enamel matrix removal could affect crystal growth, resulting in different magnitudes of enamel porosity at the time of eruption. As of right now (2002) there is no evidence that Fl affects proliferation or differentiation of the enamel organ cells, or the production and secretion of enamel matrix proteins/proteases within the dose range that can cause FL in humans.

The article contends that most likely, the Fl ion indirectly interferes with protease activities by decreasing free Ca concentration in the mineralization process. Ca regulation of these activities is extremely important.
Because the cariostatic effect of Fl is not due to its uptake by the enamel during tooth development, it is possible to obtain substantial caries reduction without a risk of dental FL.

Key points/Summary:
FL is caused by long term ingestion of Fl during tooth development. Even very low amounts of Fl intake may result in a low level of FL. The dose-response relationship is linear, and there is no critical threshold for Fl intake below which the effect on enamel will not be seen. Fl exerts its pathogenic role through alteration of Ca activities, and thereby Ca dependent proteases. More research is needed overall

Assessment of Article:
Very long, intense, specific, tedious article filled with an extreme amount of information. I had to read it three times to soak it all in. Biochemistry overload. I hope that the boards will be more general in asking a question about this… hopefully.

Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Taurodontism in Children w/ Hypodontia and Supernumerary Teeth: A Case Control Study
Author(s): Wayne Kan, BDsc, DClinDent, et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2009. V 32 NO 2. 134-140

Major topic: Taurodontism (TD)
Overview of method of research: 120 cases of children w/ TD were selected from a dental schools patient base. 83 of the children had hypodontia, and 37 children had supernumerary teeth. The crown-body root ratios of the permanent first molars of these children were compared with the same teeth in ‘normal’ case controls. The teeth were examined using the Seow and Lai technique. The teeth were outlined on an OPG and were traced by a single examiner.

Findings:
TD was first used to describe a characteristic molar trait seen in Neanderthal fossils. The definition of TD molars is teeth that have a tendency for the body of the tooth to enlarge at the expense of the roots. TD can be found in both primary and permanent teeth. TD can exist as either as an isolated trait or as a feature of multiple system malformation syndromes such as ectodermal dysplasia, Klinefelter syndrome, Down syndrome, trichodento-osseous dyplasia, and x-linked hypophosphatemic rickets, amelogenesis imperfecta and hypodontia. The etiology of TD is still unknown, however it has been proposed that it’s a result of disrupted developmental homeostasis, and involves a delayed invagination of Hertwig’s epithelial root sheath.

Key points/Summary:
In children with hypodontia, only the girls showed a significantly higher tendency for TD compared to the controls. This is likely to be a genetic issue, and possibly related to the x-chromosome. Boys with hypodontia showed a similar prevalence of TD to normal teeth. Children who had multiple missing teeth were significantly more likely to have TD than children who had one tooth missing. Conversely, TD in children with SN teeth was similar to the control group. Teeth with TD showed a higher prevalence of root resorption during ortho treatment, although this observation has not been confirmed. TD teeth also pose issue for endodontic and prosthodontic therapy (never place a post in a tooth with TD). More studies are needed on all of these subjects

Assessment of Article: Simple, basic knowledge article. Good information. Only one examiner makes the results standardized, but it also only gives us one persons view concerning the teeth. Most importantly, things to take away from this article for boards are
1. TD is associated with nonsyndromic hypodontia in girls, but not with nonsyndromic children with SN teeth
2. Children with multiple missing teeth are more prone to TD than a child who is only missing one tooth

Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Resident: Roberts

Date: 1/26/11

Author: Shabtai Sapir

Journal: Pediatric Dentistry

Volume: 29 Number: 4

Year: 2007

Title: Clinical Solutions for Developmental Defects of Enamel and Dentin in Children

Discussion

Developmental defects of enamel(DDE) consist mainly of hypoplasia and of diffuse demarcated opacities. Fluorosis, Amelogenesis imperfecta, and even dentinogenesis imperfecta may be considered developmental defects of the enamel. Often times a patient who presents with DDE will complain of poor esthetics, thermal sensitivity, attrition, secondary caries, tooth discoloration, malocclusion and periodontal problems. It is upto the clinician to take into account the patients chief complaint and whatever other complications may present with the condition and treatment accordingly for the best result possible.

Prevention

When possible preventative treatment can an important step in managing a patient with DDE. This consist of early detection, often noted at the early eruptive stages of the 6 year molars as well as along with the anterior incisors. When detected, oral hygiene instruction may include proper toothbrushes and techniques as well as desensitizing toothpaste if necessary. A weekly topical fluoride gel or varnish application and daily sodium fluoride rinse may improve resistance to demineralization, decrease tooth sensitivity, and enhance enamel remineralization as well as post eruptive maturation. The use of a sealant early on may be appropriate when possible. Mechanical preparation of the enamel prior to application is not desirable unless integrity of the enamel has already been compromised

Thoughts about which adhesive system to use

The shear bond strength of resin composite bonded to hypo-mineralized enamel is significantly lower than bonding to normal enamel. Phosphoric acid, most commonly used for enamel etching, may cause more enamel loss than self-etching primers, reducing the adhesion to hypo-mineralized enamel. Self-etching adhesives( which are hydrophilic, bond chemically and micro-mechanically) may offer an alternative that better meets the challenge of adhesion to hypo-mineralized enamel.

Treatment

Treatment depends on the severity of the condition. A definite correlation between color and porosity, mineral content, and depth has been established. Yellow-brown defects tend to be deeper extending all the way to DEJ. Whereas white creamy defects are usually less porous and variable in depth.

mild cases of hypoplasia and fluorosis

Usually no treatment is indicated unless small and minor lesions exist. If this is the case enamel micro-abrasion can be performed but caution must be taken to not remove to much of the surface area compromising the integrity of the rest of the tooth. Fluoride applications and bleaching can also have a positive effect with these cases.

moderate cases of hypoplasia and fluorosis

Micro-abrasion may be considered. When moderately significant tooth structure is removed then a composite restoration should be considered to restore form and function. Self-etching primers are not recommended in moderate and severe fluorosis, as they provide a lower shear bond strength.

severe cases of hypoplasia and fluorosis

Crown restorations with resin composites, polycarbonate crowns, laminate veneers, or porcelain crowns may be indicated in these circumstances. If severe DDE is suspected the earlier the treatment the better the prognosis. For lesions not associated with fluorosis, self etching primer is preferred. When the defects involve proximal surfaces RSC can be very retentive and esthetic, when posterior teeth are involved or the state of hypoplasia is so severe polycarbonate or cast crowns is preferred and has been proven to be more durable. With severe fluorosis and AI a pre-rinse with 5% NaOCL can improve the mechanical and chemical bonding of the adhesive for better results.

Treatment of DI

The primary dentition is usually affected more often than the permanent dentition. Intracoronal restorations and veneers may be considered for anterior teeth. External bleaching has a history of producing positive results. Most posterior teeth are severe and require early restoration with SSC’s. In the anterior dentition RSC may not have good results due to adhesive problems. Anterior permanent teeth that erupt should however be covered with composite until they fully erupt to avoid attrition and then have a RSC, polycarbonate crown placed until a PFM crown can be placed at a later date.

Conclusion

Early detection and preventative measures may go along way to maintaining the health of a compromised dentition. Educating the parents so that definitive action can take place will be necessary for a good long term prognosis.