Effects of oral habits' duration on dental characteristics in the primary dentition

Resident: Adam J. Bottrill
Date: 08JUN11
Region: Providence
Article title: Effects of oral habits' duration on dental characteristics in the primary dentition
Journal: JADA
Page #s: 1685-1693
Vol:No Date: 132, Dec 2001
Major topic: Oral Habits, Primary Dentition
Minor topic(s): None
Type of Article: Longitudinal Study

Main Purpose: The purpose of this study was to assess the effects of different durations of nonnutritive sucking habits on the occlusal relationships and the dental arch characteristics in the primary dentition.

Key points in the article discussion:

I. General:
A. Studies have demonstrated that long-term nonnutritive sucking habits can lead to occlusal abnormalities. Not much known about habits of shorter duration.

II. Methods:
A. Longitudinal data collected on nonnutritive sucking among children through a series of questionnaires. (547 children)
B. Ages 4-5, study models obtained. (526 children)
C. Excluded those with permanent dentition and insufficient descriptive data. (372 children)
D. Dental arch parameters measured
E. Occlusal conditions analyzed for the groups of children with nonnutritive sucking habits of different durations.

III. Results:
A. Only 8 of the 372 children reported no sucking habit.
B. Children with nonnutritive sucking habits that continued to 48 months of age or beyond demonstrated many significant differences from children with habits of shorter duration:
1. narrower maxillary arch widths, greater overjet and greater overjet and greater prevalence of open bite and posterior crossbite.
C. Even when the habit was ceased between 2-3yo, pts still had increased risk of developing posterior crossbite and increased mandibular arch width when compared to those ceasing at 12mo.
D. Those who ceased at 36mo vs 12mo of age had significantly greater mandibular canine arch widths, maxillary canine arch depths and overjet and open bite.
E. Prevalence of anterior open bite, posterior crossbite and excessive overjet increased with duration of habits.

IV. Conclusions:
A. Children with shorter sucking habits also have detectable differences in dimensions
B. As pediatric dentists, we may consider revisiting our suggestions that sucking habits may last until permanent dentition eruption with little concern.
C. Will attempt to follow the children into mixed dentition and draw further conlclusions.
D. Recommending children stop habits prior to 24 months of age is unrealistic.
E. The results of this study suggest 24 months is a realistic and beneficial age to begin the tapering and ceasing of nonnutritive sucking habits.

Assessment of Article: These sucking habits were followed on an ongoing basis and at regular intervals, rather than relying on retrospective gathering of the data. As an observational cohort study, it was not limited to those children "seeking treatment" which lends to it's validity. HOWEVER... This article describes something I believe we all consider intuitive. Longer habit = worsened occlusion

Oral Lesions in HIV Infection in Developing Countries: An Overview

Resident: Adam J. Bottrill
Date: 01JUN11
Region: Providence
Article title: Oral Lesions in HIV Infection in Developing Countries: An Overview
Journal: Adv Dent Res
Page #s: 63-68
Vol:No Date: 19, Apr, 2006
Major topic: HIV Infection. Oral Lesions
Minor topic(s): None
Type of Article: Descriptive article

Main Purpose: The objective of this work was to ascertain the nature and prevalence of oral lesions in different regions, and to identify any gaps in our understanding of these lesions in HIV disease.

Key points in the article discussion:

I. General:
A. Studies are needed WRT these oral lesions in developing countries and developed countries if a proper course of treatment is to be effectively formulated.
B. End of 2003: 46mill ppl infected... with more than 95% from developing countries.
C. Oral lesions are often an early finding in HIV infection.
D. 2.9 million children with HIV.

II. Methods:
A. Oral lesion reports from developing countries over a 14 year period.
B. Reports sub-grouped into 4 groups, based on region: India, Thailand, Africa, Latin America.

III. Results:
A. Detailed report and data tabulation presented in article...
B. Route of transmition primarily sexual for adults... with the exception of the Thai cohort which showed predominately IV drug use.
C. Men primarily infected with women as the majority in Zaire, Kenya, Zambia and Thailand.
D. Pediatric patients with oral lesions ranged from 25% to 63%.
E. Oral Candidiasis most common with the most common type of pseudomembranous.
F. Angular Cheilitis and Oral Hairy Leukoplakia reported from ALL regions.
G. Other common lesions: Gingivitis, Periodontitis, Linear gingival erythema, necrotizing ulcerative periodontitis, ulcers, oral hyperpigmentation.
H. Oral Kaposi's Sarcoma most prevalent in Mexico and Zimbabwe.
I. Oral submucous fibrosis in India due to areca nut chewing.
J. Often, the predominance of certain oral lesions was a direct effect of the populations access to care or stage of disease.

Assessment of Article: This article serves as a baseline for further studies regarding geographic prevalence and the nature of the disease process.

Dental Care in Children With Developmental Disabilities: Attention Deficit Disorder, Intellectual Disabilities, and Autism

Resident: Adam J. Bottrill
Date: 18MAY11
Region: Providence
Article title: Dental Care in Children With Developmental Disabilities: Attention Deficit Disorder, Intellectual Disabilities, and Autism
Journal: Journal of Dentistry for Children
Page #s: 84-91
Vol:No Date: 72:2, 2010
Major topic: Developmental disabilities, ADD, Autism, Dental care
Minor topic(s): None
Type of Article: Descriptive article

Main Purpose: The purpose of this article was to describe the characteristics of 3 common developmental disabilities and the challenges these issues present to the oral health care practitioner.

Key points in the article discussion:

I. General:

A. 13% of all children peat the MCHB definition of children with SCHN.
B. SHCN Children almost twice as likely to have unmet oral healthcare needs.
C. Considerations: speciale diet, medication, self-unjurious behavior, communication problems, orofacial malformations,

II. ADHD
A. Prevalence of 4-12% with persistence into adolescence of 60-80%
B. Impulsivity, inatention, hyperactivity... I'm sorry, but this paragraph makes me laugh. It describes almost every child with whom I've ever interacted.
C. Three types:
1. Hyperactivity/Impulsivity
2. Inattentive
3. Combined
D. Suggestions for Tx:
1. Frequent breaks
2. Reinforcement of positive behavior.
3. Those children on meds may be more behaved after taking them.

III. Intellectual Disability (mental retardation)
A. Sub-average functioning in 2 or more of the following areas: communication, self-help, home living, social and interpersonal skills, use of community resources, self-direction, health, safety, leisure, work
B. Prevalence: 1%
C. Mild/Moderate/Severe/Profound
D. ID children often have co-morbidities
E. Anxiety and uncooperative behavior in the dental setting.
F. Abnormal tooth eruption, maloclusions, missing/fused teeth, microdontia, abnormal jaw structure, macroglossia, perio disease.
G. Latex allergy, cardiac problems
H. knowing the child's mental age will help with behavior management. Manage to the "mental age".
I. Communicate to the patient's level: reward behavior, verbal reinforcement.
J. Communicate with the parents in order to gain useful tips on how to control behavior.
K. "Desensitization visits", picture books, "blanky/bobo"

IV. ASDS
A. Autism, Asperger S, PDD
B. Prevalence: 6.5/1000
C. Common deficits include: language, social skills, restricted stereotyped patterns of behavior
D. Prevalence of ID in those with ASD: 50-60%
E. Unusual responses to common smells, tastes, textures
1. Can interfere with hygiene and nutrition
F. Higher prev of obesity
G. Challenging behaviors more prev during childhood than adolescence... ALTHOUGH rapid increases in size and strength make any of these behaviors more dangerous.
H. Sources of discomfort can always bring about behavior changes... Important to take thorough med history.
I. Generally, ASD kids have good oral health and average caries and perio rates.
J. Encourage parents and teachers to use NON food rewards.
H. Some medications have side effects including weight gain, abnormal movements and increased risk of diabetes.
I. Visual supports to increase chances of succesful visit: schedules, "social stories", books, pictures.
J. Some dentists keep a copy of a social story to send to families prior to visit.
K. Use the same staff, appointment time, day of the week etc...
L. ASK THE PARENTS... about everything.

Assessment of Article: The title of the article doesn't seem to accurately depict the content.

Guideline on Prescribing Dental Radiographs for Infants, Children, Adolecents, and Persons with Special Health Care Needs.

Resident: Adam J. Bottrill
Date: 23MAR11
Region: Providence
Article title: Guideline on Prescribing Dental Radiographs for Infants, Children, Adolescents, and Persons with Special Health Care Needs.
Journal: Pediatric Dentistry Reference Manual
Page #s: 272-274
Vol:No Date: 2010
Major topic: Dental Radiographs
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: This guideline is intended to help practitioners make clinical decisions concerning appropriate selection of dental radiographs as part of an oral evaluation of infants, children, adolescents, and persons with special health care needs.

Key points in the article discussion:

I. General:

A. The recommendations in past ADA/FDA guidelines were developed to serve as an ADJUNCT to the dentist's professional judgment.
B. Timing of initial radiographic exam should be based on individual circumstances.
C. Should be performed only when there is an expectation that the Dx yield will affect patient care.
D. If radiographs of diagnostic quality are unobtainable, practitioner should confer with parent to decide on proper management techniques (in office, increased recall frequency, OR etc...)
E. ALARA (Time, Distance, Shielding)
F. Cone Beam CT is being researched and investigated for potential use in dentistry

II. Recommendations:

























A. Recommendations are subject to clinical judgement and may not apply to every patient.
B. Protective aprons and thyroid collars should be used whenever possible.
1. Strongly recommended for children, pregnant women, and women of child-bearing age.
C. When using CBCT, should follow all guidelines of the AAOMR and provide written supplement to any imaging that is included in the patient chart.


Assessment of Article: Radiation and radiographs can be a touchy subject. It's good to have "policy" to back up our decisions regarding this aspect of patient care.

Guideline on the role of Dental Prophylaxis in Pediatric Dentistry

Resident: Adam J. Bottrill
Date: 23MAR11
Region: Providence
Article title: Guideline on the role of Dental Prophylaxis in Pediatric Dentistry
Author(s): Clinical Affairs Committee
Journal: Pediatric Dentistry Reference Manual
Page #s: 141-142
Vol:No Date: 2010
Major topic: Prophylaxis
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: Provide a guideline for the indications for and benefits of a dental prophylaxis in conjunction with periodic infant oral health assessment.

Key points in the article discussion:

I. General:

A. Microbial plaque is the primary etiological factor in caries and periodontal disease. MOST of this plaque can be removed with home hygiene, but MOST patients do not have the necessary skillz to remain plaque-free for long periods of time.

B. Indications:
1. Removal of plaque, stain, and calculus.
2. Elimination of factors that influence the build-up and retention of plaque.
3. Demonstration of proper oral hygiene methods to the pt/caregiver.
4. Facilitation of a thorough clinical exam.
5. Introduction of dental procedures to the child.

C. Type and frequency varies based on individual risk-assessment:
1. MH.
2. Age and cooperation.
3. Compliance.
4. Past and current caries.
5. FH of caries.
6. Past and current perio health.
7. FH of perio health.
8. OH.
9. Plaque.
10. Calculus.
11. Staining.
12. Local factors that would influence the build-up and retention of plaque.

D. Prophy can be performed with TB, cup, floss, instruments.
1. With no stain or calculus, TB is ok.
2. Rubber cup prophy for extrinsic staining and smoothing edges after scaling.
3. Rubber cup using pumice may be used prior to Fl Tx.
4. abrasive toothpastes and pumice may remove pellicle which may increase chances of enamel loss through exposure to dietary acids.
5. Pumice may remove up to 0.6-4.0 microns of outer enamel (includes the Fl-rich layer).

II. Recommendations:

A. Periodic Prophy should be performed to:
1. Instruct.
2. Remove plaque and calculus.
3. Polish hard surfaces.
4. Remove staining.
5. Facilitate the exam.
6. Introduce dental procedures to young children and apprehensive patients.

B. Practitioner should choose the least aggressive technique that fulfills the goals of the procedure. Least abrasive paste with light pressure.

C. If pumice or course past is used, Fl application indicated.

D. Patients at higher risk should have prophy at more frequent interval than 6 months.
1. Allows for OH monitoring and frequent Tx.

E. Individualized Tx plans are necessary.

Assessment of Article: Short and sweet and common sense. I suppose the AAPD needs to have this guideline, but it seems silly. I'm glad they didn't waste more than 2 pages.

Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents

Resident: Adam J. Bottrill
Date: 16MAR11
Region: Providence
Article title: Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents
Author(s): Clinical Affairs Committee
Journal: Pediatric Dentistry Reference Manual
Page #s: 93-100
Vol:No Date: 2010
Major topic: Periodicity of various services.
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: This guideline is meant to help practitioners make clinical decisions concerning preventative oral health interventions, including anticipatory guidance and preventative counseling, for infants, children, and adolescents.

Key points in the article discussion:

I. General:

A. The AAPD recommends initiating professional oral health intervention in infancy and continuing through adolescence and beyond.

II. Clinical Oral Examination:

A. Components of a comprehensive oral examination include assessment of:
1. General health, pain, extraoral soft tissue, TMJ, intraoral soft tissue, OH, perio health, intraoral hard tissue, occlusion, caries risk, behavior.
2. 6mo interval is typical however frequency may be increased based on clinical need.

III. Caries Risk Assessment:

A. KEY element of preventative care.
B. Prevention by identifying causative factors and optimizing protective factors.
C. Risk assessment must be repeated regularly due to changes in habits and development of the child.

IV. Prophylaxis and Topical Fluoride Treatment.

A. Many patients lack the skill or motivation to become and remain plaque-free for a significant time.
B. Hormonal changes can effect oral microflora.
C. Caries risk changes with age and eruption pattern.
D. Prophylaxis and fluoride treatment is typically 6mo intervals however each patient must have an individual treatment plan.
1. Moderate risk: every 6mo
2. High risk: more frequent

V. Fluoride Supplementation:

A. The AAPD encourages optimal fluoride exposure for every child, recognizing fluoride in the community water supplies as the most beneficial and inexpensive preventive intervention. Supplementation should be considered when exposure is not optimal. Supplementation should be in accordance with the jointly recommended guidelines of AAPD, AAP, ADA and CDC.... in my opinion, THIS IS A COP-OUT STATEMENT.

VI. Anticipatory Guidance:

A. Thorough discussion should occur at every appointment through the patient's life. This is the only way to properly keep track of the changes in habits and risk factors in order to discourage risky behavior and promote proper oral health.
B. High risk dietary habits begin by 1yo.
C. Include injury-prevention counseling.
D. Non-nutritive sucking habits encouraged to stop by 3yo
E. Speech referals if needed.
F. Smoking and smokeless tobacco use becomes an issue later in childs life.
G. Let's not forget INTRAORAL PIERCINGS! ... bad bad bad

VII. Radiographic Assessment:

A. Timing should not be based on age. Instead review of dental history and full exam.
B. ALARA

VIII. Tx of Disease:

A. Immediate and timely intervention (just like St. Joseph!)

IX. Ts of Malocclusion:

A. Early Tx of malocclusion.
1. Reversing adverse growth
2. Preventing dental and skeletal disharmonies
3. improving aesthetics of the smile
4. improving self image
5. improving occlusion

X. Sealants:

A. Reduce the risk of pit and fissure caries in susceptible teeth and are cost-effective when maintained.

XI. Third Molars:

A. Pan or PA assessment is indicated during late adolescent life. Decision to remove should be made before mid-twenties.

XII. Referral for Regular and Periodic Dental Care:

A. Proper education and transition to an adult dentist. Don't just leave the patient hanging.
B. Until the Pt has found appropriate adult dental care, he/she should maintain relationship with pedo for emergency services.

XIII. Recommendations by Age:






















Assessment of Article: It's the reference Manual. It's the "standard of care". Know it. Love it.

Sickle Cell Anemia: A Review for the Pediatric Dentist

Resident: Adam J. Bottrill
Date: 09MAR11
Region: Providence
Article title: Sickle Cell Anemia: A Review for the Pediatric Dentist
Author(s): Fonseca, Marcio A. et al.
Journal: Pediatric Dentistry
Page #s: 159-169
Vol:No Date: 2007
Major topic: Sickle Cell Anemia
Minor topic(s): None
Type of Article: Topic Summary and Discussion

Main Purpose: Provide a comprehensive review of Sickle Cell Anemia

Key points in the article discussion:

I. General:

A. Sickle Cell Anemia (SCA)is an inherited defect that affects the structure and synthesis of hemoglobin.
B. Alpha and Beta Thalassemia and SCA are the most common types of hemoglobinopathies worldwide.
C. SCA: most frequent genetic disorder. Found often in African, Mediterranean, Middle Eastern, Indian, Caribbean, Central American and South American.
D. Comprises sickle cell trait and sickle cell disease (SCD)
E. SCD: hemolysis, chronic organ damage, unpredictable acute life-threatening complications.
G. Trait: Benign. 8% of African Americans and 10-30% of equatorial Africans.
H. HbS (sickle hemoglobin) carriers protected from Malaria.

II. Pathophysiology:

A. Polymerization of deoxygenated HbS... "single, indispensable event in the path..."
B. Lifespan of sickle RBC=12-17 days (normal=120).
C. Sickle cells caught in slow-flowing venular side of microcirculation.... increased adhesion to endothelial walls and local hypoxia increased HbS polymer formation and spread of occlusion to adjacent vasculature. Increased inflammation.
D. Problem becomes "erythrocitic sticking" rather than simple "sticking". Other problems include adhesion, hemolysis, deformation.
E. Symptoms arise from chronic endothelial damage instead of acute erythrocyte formation. "chronic inflammatory vascular disease"

III. Systemic manifestations:

A. Symptoms begin within 1st 6 mo of life: evolving organ damage with intermittent pain and pulmonary complications.
B. Genotype most effects the clinical severity.
C. "Crisis" usually occur due to other illnesses, dehydration, temperature changes, hypoxia, stress and menstruation.
D. Other symptoms: Short stature, deformed bones, PAIN, PAIN, PAIN, splenic sequestration crisis, cardiomegaly, systolic murmors, CHF, osteomylitis, osteonecrosis, marrow hyperplasia, acute chest syndrome (leading cause of death and hospitalization among SCD patients), cerebrovascular events, impaired psychosocial function, altered inter-intrapersonal relationships, altered sexuality, poor body image, social withdrawal, poor academic functioning, marital problems.

IV. Prevention and Tx:

A. Hydroxyurea (marrow suppression) has been shown to decrease crisis occurrences and pain. Remains unlicensed in most countries due to unknown long term side effects.
B. Being studied: Vascular lubricants, xanthine oxidase inhibitors, nitric oxide enhancers, gardos channel inhibitors, monoclonal AB's, statins, gene therapy.
C. ONLY current available curative therapy is hematopoietic stem cell transplantation which is needed if organ dysfunction occurs.
D. Pain usually managed at home with opioid and non-opioid meds, massage, heating/cooling, electric nerve stimulation.
E. Splenic sequestration: correction of hypovolemia with a transfusion. If it occurs 2-3 yo, spenectomy. Lifetime of AB prophylaxis.
F. Blood Transfusions:
1. increase oxygen-carrying blood
2. improve end-organ perfusion
3. Indications: severe symptoms, splenic sequestration, ACS, acute organ damage, surgery
4. NOT indicated: stable compensated anemia, infections without aplastic crisis, minor surgeries, uncomplicated acute painful crisis.

V. SCD and GA:

A. Dental restorations and simple extractions may be performed on low-risk patients. Moderate risk and high risk must go to OR.
B. NIH recommends simple transfusion prior to all but low risk procedures such as dental, optha etc....
C. Goal of GA management remains meticulous attention to the basic principles of safe anesthesia.

VI. Oral/Dental/Craniofacial Manifestations.

A. Jaundice mucous membranes, glossitis, pallor of tongue, delayed tooth eruption, decreased radiodensity, abnormal radiographic bone presentation, radioluscent teeth, bimaxillary protrusion, flared incisors, tower skull, hair-on-end appearance, granular appearance of skull, mandibular osteomylitis (men),
B. Possible oral pain in the absence of odontogenic pain due to occlusive crisis in the microvasculature of facial muscles.
C. Crisis MAY be precipitated by perio infection, pericoronitis.
D. Possibly a lower caries rate due to long term antibiotic use by those with the disease. Lowered caries rate falls off later in life due to stopped AB use.

VII. Dental Management:

A. HISTORY HISTORY HISTORY
1. Complications, pain episodes, med tx, catheters, blood-born viruses due to transfusions, growth and development.
2. Social and coping issues.
B. Removal of any potential infections must be performed.
C. Painful teeth should be treated seriously.
D. No conclusions have been drawn WRT best pulp therapy.
E. Restorations preferable to extraction.
F. Facial swelling or celulitis may warrant hospitalization.
G. Operative during NON crisis periods.
H. CBC should be done before any invasive dental procedure if the patient is taking HU.
I. No official rec regarding altering Tx due to SCA pts taking bisphosphonates.
J. No evidence supporting using anesthesia withOUT vasoconstrictor.
K. N2O is ok... but care to AVOID hypoxia. Max 50% and pt should breathe 100% O2 for a few minutes following.
L. Need for AB proph remains controversial (some use for endocartditis while others use to prevent systemic infection).
M. Elective surgeries should be avoided.
N. No contra-indications for ortho... unless non-compliance with OH.
O. PHYSICIAN SHOULD BE CONSULTED!!!

Assessment of Article: QUALITY article. Good scientific review, medical considerations, dental considerations, GA considerations!! The ULTIMATE SCA REFERENCE ARTICLE!!!!! Don't think I've ever been this enthusiastic about an article. Don't worry, it won't happen again.

Immune Thrombocytopenia

Resident: Adam J. Bottrill
Date: 02MAR11
Region: Providence
Article title: Immune Thrombocytopenia
Author(s): Cuker, Adam et al.
Journal: Hematology
Page #s: 377-384
Vol:No Date: 2010
Major topic: Immune Thrombocytopenia
Minor topic(s): None
Type of Article: Topic Summary and Discussion

Main Purpose: Provide a comprehensive review of immune thrombocytopenia

Key points in the article discussion:

I. General

A. Immune Thrombocytopenia (ITP) is an autoimmune syndrome inolving AB and cell mediated destruction of platelets and suppression of platelet production that may predispose a pt to bleeding. This review focuses on PRIMARY ITP in ADULTS.
B. No current studies on observed untreated ITP because most patients present with bleeding problems that require treatment.

II. Demographics:

A. Incidence: 1.6-3.9 per 100,000 persons per year.
B. Prevalence: 9.5-23.6 per 100,000 persons per year (UK). US stats are lower.
C. Due to vagaries in Dx codes, these numbers may be low.
D. Younger adults: Females>Males, Older Adults: Females=Males.

III. Etiology:

A. Underlying defects are unknown.
B. Heritability is uncommon.
C. "Molecular mimicry" seems to play a role in formation of anti-platelet antibodies after certain vaccinations or viral infections (HIV, Hep C).

IV. Pathogenesis:

A. Platelet life-span is reduced as a consequence of AB-mediated clearance by tissue macrophages.
B. Possible involvement of other mechanisms: AB-mediated apoptosis, antigen shedding and T-cell mediated platelet destruction or marrow suppression.

V. Dx:

A. Primary ITP is Dx of exclusion from both NON-autoimmune causes and secondary causes.
B. Can be quite difficult without historic platelet count.
C. 20% of ITP in USA is secondary.
D. Often, Pt's assumed to have primary ITP are found later to have secondary.
E. Uncommon for pt's presenting with ACTUAL primary ITP to develop another clinically overt autoimmune disease.
F. 150 x 10^9 / L ... needed level of platelets for the Dx currently.
G. In general, the incidence of remission lessens as the duration of the disease increases.
1. This has led to the SUB-Dx of: Newly Dx (<3mo),>12mo)

VI: Management:

A. Principles: Goal of Tx is to provide a protracted platelet count of >30x10^9/L while minimizing toxicity.
B. Platelet count: (evidence suggests it is predictive of serious bleeding in ITP)
1. Other LIFE factors that effect platelet level and bleeding risk must be considered when treating patients with ITP (age, activity level, medications etc...)
C. Remission: Early intervention CRICIAL as more chronic ITP patients can develop stronger, mor specific auto-antibodies.
D. Quality of Life: Patients with ITP tend to experience fatique, apprehension of bleeding, withdrawl from normal daily activities.
E. Who to Treat: Typically don't treat when platelet count greater than 30x10^9/L. However may consider treating surgical patients due to increased risk of bleeding.

VII. 1st-line therapy for Newly Dx:

A. Corticosteroids with supplemental immunoglobulin or anti-RhD as needed to stop bleeding and increase platelet count.
B. Studies being performed with Dexamethasone and anti-CD20 AB.

VIII. Hospitalization and Emergency Therapy:

A. ITP patients should be hospitalized if: Internal bleeding, platelets under 10 and Hx of sig bleeding or non-compliance, platelets of 10-20 for pt's who have not been effectively treated yet. Otherwise, outpatient setting is appropriate.
B. Platelet transfusion appropriate in case of life-threatening emergency, organ-threatening emergency or head trauma.

IX. 2nd-line Therapy:

A. Should be used in the absence of robust response by one of the 1st-line therapies.
B. Fewer steroid dosages, or lower level of steroid-sparing agents.
C. Splenectomy: 2/3 of pt's obtain long term remission.
1. Complications and risks extensive... HOWEVER it is low cost and highly effective.
D. Anti-CD20: Single course induces complete remission in approximately 40% of Pt's.
1. Clinical trials in process for a number of CD-20 drugs.
E. TRA's (thrombopoeitin receptor agonist): Two types currently approved by FDA for primary ITP treatment.
1. Possible side-effects include rebound thrombocytopenia with lower counts than before therapy. Careful administration of these drugs in NECESSARY.

X. 3rd-line Therapy:

A. Multiple immunosuppresive agents have been tested but are only used as "last resort" due to their quesitonable "safety profile".

XI. Summary:

A. ITP is a syndrome of various disorders that have in common immune-mediated thrombocytopenia,
B. As understanding of ITP grows, the Dx of PRIMARY ITP will apply to a smaller and smaller group of individuals.
C. The cause of impaired platelet poiesis remains uncertain.
D. TRA's APPEAR capable of overriding AB-mediated platelet clearance in most patients.
E. Platelet count is the current diagnostic tool of choice but hopefully will be replaced someday by biomarkers of pathogenesis or response.
F. There is still a school of thought that spontaneous remission may likely occur, but this is being challenged by a high response rate in EARLY, AGGRESSIVE intervention.
G. Long term, prospective studies still needed for MANY of the new therapies.
H. Currently, the most reliable and cost-effective solution for second-line therapy is corticosteroids followed by splenectomy... keeping in mind long term side-effects of splenectomy and steroid use.
I. Currently, TRA's pose the most exciting front line of treatment options.

Assessment of Article: Clinically, this article doesn't have much practical application. However, it does educate us on the path, Dx, and Tx of the disease. The take-away from the article is to have more of an awaremess of how ITP (primary AND secondary) may effect our pt's bleeding tendancy. Also, given a platelet count and ITP Dx, we should know when a hospital referal is indicated. Good, THOROUGH article.

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.

Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehab

Resident: Adam J. Bottrill
Date: 26JAN11
Region: Providence
Article title: Local Anesthesia Affects Physiological Parameters and Reduces Anesthesiologist Intervention in Children Undergoing General Anesthesia for Dental Rehabilitation
Author(s): Watts, Amy K. DDS, MS
Journal: Pediatric Dentistry
Page #s: 414-419
Vol:No Date: 31:5, SEP/OCT 2009
Major topic: Local Anesthesia, General Anesthesia, Children
Minor topic(s): NA
Type of Article: Randomized, parallel-design study
Main Purpose: The purpose of this article was to evaluate the use of intraoperative local anesthetics in pediatric outpatient dental surgery. It assessed physiological stability, as defined by fluctuations in end-tidal CO2, HR, RR and subsequent anesthesiologist intervention.

Key points in the article discussion:

I. General:
A. Pain is both a real emotional and physiological respoonse
B. Research suggests that the use of regional anesthesia can reduce the amount of required inhaled general anesthesia.
C. LA, in conjunction with GA can produce a more hemodynamically stable patient AND control pain in the immediate post-operative period.
D. IDEAL ANESTHETIC AGENT: immobility, amnesia, , sedation, analgesia/nociception, arousal blockade with a pharmacological profile that possesses a wide margin of safety.
E. Currently, no guidelines by either the ASA or the ADA for use of local anesthesia during GA dental rehab. AAPD states that LA "may be used" to reduce pain in post-op period.


II. Methods:
A. Pilot study was conducted for feasability purposes
B. 48 children (mean age of 3.87) undergoing GA
C. Inclusion Criteria
1. 12-84 mo
2. at least one maxillary extraction.
3. rubber dam clamp in maxilla
4. at least one primary tooth needing pulp/crown
5. ASA I or ASA II
D. One dental anesthesiologist used for all GA's
E. Two groups: LA and NON-LA
F. LA administered prior to procedures (for LA group)
G. 2% xylocaine was given in the LA group
H. No patient exceeded 4.4mL of LA
I. Vital sign changes recorded 30 seconds after each procedure.
J. Anesthesiologist intervention was with 10 mg boluses of propofol
K. Intervention if: movement, breath holding, 20% increase in vital signs, ETCO2 <40mm Hg
B. Two groups: LA and NON-LA
C. LA administered prior to procedures (for LA group)
D. Vital sign changes recorded 30 seconds after each procedure.

III. Results/Discussion: (pooled data)
A. NON-LA group: changes in vital signs were statistically significant for two parameters.
1. Post extraction ETCO2
2. Post extraction HR
B. Interference: Different patients have different tolerability for changes in vital signs from baseline.
C. Weaknesses:
1. The exact amount of anesthesia received by each tooth was not able to be controlled.
2. Order of procedures was decided by the dentist.

IV. Conclusions:
A. Patients who were not given intraoperative local anesthesia were more likely to experience vital sign fluctuation requiring anesthesiologist intervention.

Assessment of article: I thought it was an efffective, thorough study. I wish there was more statistical significance to some of the other parameters and procedures. The conclusions seemed to only follow what is already known anecdotally. Despite this fact, it is nice to have an actual article backing up existing practice.

Pharmacological Management of the Pediatric Patient

Resident: Adam J. Bottrill
Date: 19JAN11
Region: Providence
Article title: Pharmacological Management of the Pediatric Patient
Author(s): Wilson, Stephen DMD, MA, PhD
Journal: Pediatric Dentistry
Page #s: 131-135
Vol:No Date: 26:2, 2004
Major topic: Behavior Management, Sedation, General Anesthesia
Minor topic(s): NA
Type of Article: Conference Paper

Main Purpose: Provide an overview of the various forms of pharmacological management of pediatric dental patients.

Key points in the article discussion:

I. General:

A. Society demands not only efficient, but HUMANE ways of administering behavior management.
B. Only ONE behavior management technique is consistently taught at ALL residency programs in the US... Pharmacological Management (PM).
1. PM is generally divided into two categories: Sedation and GA.
2. Hundreds of articles written about sedation... much less about GA.
C. Factors to be considered when considering PM.
1. Risks
2. Safety Record
3. Extent of dental needs
4. Practitioner competence
5. Professional support for technique
6. Monitoring
7. Cost
8. Venue
9. Parental expectations
10. Child's needs and personality
11. Integration of these factors into MO embraced by profession

II. Sedation Risks and Safety.
A. Major: brain damage and death
B. Minor: vomiting, behavior, extreme physiological parameters
C. COMPLETE med history is imperative.
1. airway issues (snoring etc...)
2. allergies
3. review of systems
4. Only children with very MILD conditions should be considered for sedation.
D. AIRWAY AIRWAY AIRWAY
E. Though pediatric patients have died due to sedation, there is no evidence that suggests death has occurred when practitioners are faithfully following guidelines.
F. It is NOT POSSIBLE to accurately calculate an official safety record WRT sedation. There is no way to generate an accurate number of SUCCESSFUL sedation attempts.

III. PM Cost and Reimbursement issues

A. Significant issue effecting choice of sedation
B. Medicaid covers enough to "break even" in most states.
C. GA is OFTEN covered for "equivalent" medical procedures.
D. So why the disparity???

IV. Training Issues

A. Risk may INCREASE with sedation (when compared to GA) due to lack of training or adherence to sedation guidelines.
B. Dental students are often not trained in deep sedation techniques due to the lack of knowledge and experience of faculty.
C. There seems to be a general attitude of "It won't happen to me" among dentists using sedation.
D. Solutions: MORE TRAINING, Resolution of the financial/political issues associated with GA

V. Professional Issues

A. Subtle professional pressures by medical anesthesiologists for the independence in the roles the roles of operator and anesthetist.
B. The author blames "financial considerations".
C. 2 or more sedation cases costs MORE than one GA case.
D. Controversy over HOM and "voice control"
E. General disagreement and lack of communication between AAP, AAPD and medical anesthesiologists.

VI. Societal and Parenting Issues

A. Parents no longer implicitly trust practitioners
B. Parental expectations are sometimes rediculo.
C. Recent surveys of AAPD members have shown that the general perceived behavior of children has deteriorated over the last few decades.
1. This correlates with the general increase in the necessity of sedation over the past few decades.

VII. Conclusions

A. GA for the healthy fearful child is extremely safe.
B. Some medical specialists are opposed to use of GA outside of the hospital however "little evidence supporting such an opinion is available."
C. PM of the pediatric patient is acceptable and desirable.
D. What is needed:
1. MORE RESEARCH ENDEAVORS
2. Dissemination of accurate information to communities
3. Collaboration of medical and dental organizations.
4. Political and business initiatives.
5. Further efforts to minimize dental disease.

Assessment of article: I'm not a huge fan of the "Conference Paper." Very opinionated and anecdotal. Not really of much use clinically.

Peripheral Ossifying Fibroma - A Clinical Evaluation of 134 Pediatric Cases.

Resident: Adam J. Bottrill
Date: 22DEC10
Region: Providence
Article title: Peripheral Ossifying Fibroma - A Clinical Evaluation of 134 Pediatric Cases.
Author(s): Elvira S. Cuisia Zenaida
Journal: Pediatric Dentistry
Page #s: 245-248
Vol:No Date: 23:3 2001
Major topic: Peripheral ossifying fibroma
Minor topic(s): NA
Type of Article: Clinical Evaluation

Main Purpose: This study, the first devoted to children, investigated the clinical features of a large number of POF's and compared the findings to cases reported in the English language literature.




Key points in the article discussion:

I. General:

A. Solitary gingival enlargements common in children. Usually due to irritation.
B. Peripheral Ossifying Fibroma:
1. Gingival nodule, cellular fibroblastic connective-tissue stroma with dispersed calcified foci.
2. Localized, exophytic lesion with sessile or peduculated base.
3. Most studies on POF's concentrate on the entire category of "fibroma's". Also, there are NO studies on POF's in the pediatric population.
4. Reactive lesions like POF do have pediatric significance that require early recognition and treatment by a dentist.
5. Definative etiology unknown
6. DD: Pyogenic Granuloma, Fibroma, Peripheral giant cell granuloma, irritation fibroma, papilloma, peripheral odontogenic fibroma

II. Methods:

A. Clinical and historical information of 134 surgically-removed POF's in patients age 1-19.
B. Clinical Manifestations, histogenesis, treatment rationale, biological behavior were emphasized.
C. 657 POF's in the 43362 biopsies during the study period. Only 134 (20%) were pediatric patients.

III. Results

A. Females (60%)
B. Maxillary Gingiva (60%)
C. Incisor/cuspid region
D. Average age 14yo (6mo to 19yo)
E. 71% of cases were found in black pts. (MAY indicated increased incidence)
F. Color: pink to reddish
G. 63% of lesions were ulcerated.
H. Size: 0.3 - 3.0 cm
I. Only 2 (1%) associated with primary teeth.
J. Clinician RARELY included POF in DD.
K. Recurrence rate after excision 8% (vary from 7-46% depending on the study)
1. This 8% may be inaccurate due to the nature of this study. There was no attempt to determine the recurrence rate of patients who did not follow up.

VI. Conclusions

A. Must consider taking radiographs, even for soft tissue lesions such as POF in order to determine the extent of the lesion and eliminate the DD.
B. POF is a well-defined pathologic entity among reactive gingival lesions.
C. Peak incidence is in the 2nd decade. Incidence of POF in 1st decade is very uncommon.
D. POF most common in female.
E. POF found mostly in maxillary incisor region.
F. POF arising from PDL of primary tooth uncommon.
G. Proper treatment protocol is warranted with close follow-up.

Assessment of article: Informative. Large "n". The author attempts to tag this study as somewhat "ground-breaking" by mentioning it's the first PEDIATRIC study of it's kind. I suppose it's interesting, but I don't see it changing the way I treat patients. The conclusions were appropriate. Medium Likey.

Compound Odontoma - Diagnosis and Treatment: Three Case Reports

Resident: Adam J. Bottrill
Date: 22DEC10
Region: Providence
Article title: Compound Odontoma - Diagnosis and Treatment:
Author(s): Branca Heloisa de Oliveira
Journal: Pediatric Dentistry
Page #s: 151-157
Vol:No Date: 23:2 2001
Major topic: Compound Odontoma
Minor topic(s): NA
Type of Article: Case Studies
Main Purpose: This paper describes 3 cases of compound odontomas diagnosed in children due to dislodgement or over-retention of primary anterior teeth and/or swelling of the cortical bone.

Key points in the article discussion:

I. General:

A. Odontomas: developmental anomolies formed of enamel and dentin with possible , variable amounts of pulpal and cement tissue. Can show anatomical similarity to teeth, in which case it labeled "compound." When it forms an irregular mass, described as "complex"

B. Major Characteristics of Compound and Complex Odontomas:




















C. Ameloblastic fibro-odontoma: General features of ameloblastic fibroma but with evidence of enamel and dentin.
1. 10yo
2. Central/Intraosseous tumors
3. Posterior Mandible
4. Well-defined, uni/multilocular radiolucent defect with variable amount of (dental) radiodense material.
5. Tx: Conservative surgical enucleation with GREAT prognosis.

D. Ameloblastic Fibrosarcoma: malignant counterpart of the ameloblastic fibroma. Usually a "re-diagnosis" of a progressing existing lesion.
1. 27.5 yo
2. Ill-defined, destructive radiolucent lesion that suggests malignant process.
3. Pain and swelling along with rapid clinical growth.
4. Tx: Radical surgical excision.
5. Long-term prognosis unsure.

E. Odontoameloblastoma: VERY RARE... with ameloblastomatous components with odontoma-like component.
1. Mandible of young patients
2. Radiolucent, destructive process that contains calcified structures.
3. Tx: Surgical resection. (curettaged lesions may reccur)
4. RARE... no known prognosis

II. Case I

A. 5 yo white female.
B. Presented with changing position of upper left primary central incisor (labially displaced and intruded). No Hx of trauma.
C. Radiographic exam: compound odontomas in palate.
D. Tx: Surgical resection. 3 tooth-like structures found within lesions.
E. When permanent teeth erupted, upper incisors proclined and midline is shifted.
F. Removable appliance used to improve position.

III. Case II

A. 12 yo female
B. Presented complaining of excess volume of gingiva in the area of upper right anterior region. No Hx of trauma.
C. Radiographic exam: compound odontoma buccal to the root of upper permanent lateral incisor.
D. Tx: Surgical resection. 7 tooth-like structures found.
E. 1 yr F/U confirmed that lateral incisor had returned to normal position. No recurrence of lesion.

IV. Case III

A. 11 yo male.
B. CC of overretained primary central incisor despite presence of permanent dentition elsewhere in the mouth.
C. Radiographic exam: odontoma-like lesion in the buccal region of primary incisor root.
D. Impacted corresponding permanent incisor.
E. Tx: Surgical removal with multiple tooth-like structures present.
F. Orthodontic device used to expose and guide tooth into place.
G. 3 years to bring into place with uneven gingival margins and incisal edge.

V. Discussion

A. The three cases were all diagnosed early and radiographically prior to excision. All found in the anterior maxilla.
B. One patient suffered trauma in the area. Some researchers claim trauma may contribute to odontoma development.
C. Delayed diagnosis (evident in case III) may result in complete root formation/impaction and necessitate surgical exposure.
D. Ideally, surgical removal of odontomas should occur when the roots of adjacent permanent teth are about half-formed.

VI. Conclusions

A. Evidence suggests that an individualized radiographic examination of any pediatric patient that presents clinical evidence of delayed permanent tooth eruption or temporary tooth displacement should be performed.
B. Early diagnosis of odontomas allows adoption of a less complex and less expensive treatment and ensures better prognosis.

Assessment of article: Good background and history of the pathology. I don't believe the author overstepped any bounds or made any rash conclusions based on these three cases. I know this may be hard to believe, but I don't have any complaints. Likey.

An In Vitro Comparrison of Marginal Microleakage of ART and Conventional Glass Ionomer Restorations in Extracted Permanent Molars

Resident: Adam J. Bottrill
Date: 15DEC10
Region: Providence
Article title: An In Vitro Comparrison of Marginal Microleakage of ART (Alternative Restorative Treatment) and Conventional Glass Ionomer Restorations in Extracted Permanent Molars
Author(s): Wadenya, Rose BDS, MS, DMD et al
Journal: Pediatric Dentistry
Page #s: 303-307
Date: V29/No4 Jul/Aug 07
Major topic: Microleakage, ART, Margins, Glass Ionomer
Minor topic(s): NA
Type of Article: In vitro comparison
Main Purpose: The objective of this study was to compare the marginal leakage of cervical restorations made using Alternative Restorative Treatment (ART) and conventional glass ionomer restorations.

Key points in the article discussion:

I. General:

A. ART, formerly "Atraumatic Restorative Treatment", was introduced to assist in the need to prevent progression of dental caries in countries where conventional dental care was not available... Tanzania.

B. AAPD recognizes ART as useful and beneficial for:
1. Young pts
2. Uncooperative pts
3. Special needs pts
4. Situations where traditional cavity preparation and restoration is not possible

C. Glass ionomer cements:
1. Fl release
2. Low shrinkage
3. Pulpal biocompatability

II. Methods:

A. 16 permanent max and mand 1st molars extracted for perio reasons with cl V caries... ART used.

B. 29 noncarious extracted molars with cl V preparations using high speed handpiece.

C. All teeth restored with Glass Ionomer cement (GIC).

D. Thermally stressed for 300 cycles and stained with methylene blue... JUST LIKE A REAL
MOUTH!

E. Sectioned and evaluated for microleakage.

III. Results:

A. No significant difference between the ART and conventional GIC restorations.

IV. Conclustions:

A. ART with GIC shows comparable marginal leakage to conventionally restored teeth.

B. For conventional restorations, more leakage is higher at the dentinal margins when compared to the enamel margins.

Assessment of article: I believe I've already explained my "raised eyebrow" opinion of some in vitro studies... this is no different for me. ALSO... I would ave appreciated a primary tooth, occlusal surface ART study more than this PERMANENT tooth, Cl V study... huh?

Effect of Adhesive Systems and Bevel on Enamel Margin Integrity in Primary and Permanent Teeth

Resident: Adam J. Bottrill
Date: 17NOV10
Region: Providence
Article title: Effect of Adhesive Systems and Bevel on Enamel Margin Integrity in Primary and Permanent Teeth
Author(s): Swanson T.K. et al.
Journal: Pediatric Dentistry
Page #s: 134-140
Date: V30/No2 Mar/Apr 08
Major topic: Marginal Integrity, Enamel Beveling, Self Etching
Minor topic(s): NA
Type of Article: In vitro, factorial-designed study
Main Purpose: The study compared the effectiveness of self-etch and total-etch adhesive systems in bonding to the beveled and nonbeveled margins of primary and permanent teeth.
Key points in the article discussion:

I. General:

A. Bonded interfaces are NOT perfect and confidence in their long-term durability is not complete.
B. "Self-etching" adhesives are being ADVERTISED as less technique sensitive, less time consuming yet just as effective as total-etch adhesives.
C. Three total steps... ETCH, PRIMER, ADHESIVE
D. Recent studies have shown there is no difference with current self-etch materials and whether or not the preparation is beveled.

II. Methods:

A. 3 Factors: tooth type, presence of a bevel, adhesive type
B. 2 preparations (beveled and non-beveled) completed on B surfaces of 60 extracted molars (30 primary, 30 permanent)
C. Randomely assigned self-etech vs total etch
D. Thermocycling.... staining.... sectioned.... measured for microleakage.


III. Results:

A. Beveled margins had less microleakage for both types of teeth.
B. Total-etch had less microleakage than self-etch adhesives. (53% primary 22% permanent !!!)
C. Self-etch had considerably more leakage on non-beveled preps
D. Comparably less microleakage for both types of etch on beveled margins.

IV. Conclustions:

A. Total etch AND beveled margins result in less leakage.
B. Beveling has greater effect on minimizing microleakage than type of adhesive.

Assessment of article: SHENANIGANS.
A. This should have been three studies. Not one... in my opinion.
B. With the self-etch method they used two coats.... WHAT'S THE POINT.
C. I rarely appreciate in vitro studies that attempt to mimic actual patient/clinical conditions.
D. Thermocycling? 131 degrees to 41 degrees? 500 times? Silver nitrate immersion?... come on man. That may be the closest they can achieve to actual conditions... still not the same as a mouth.

The Clinical and Radiographic Success of Bonded Resin Composite Strip Crowns for Primary Incisors

Resident: Adam J. Bottrill
Date: 03NOV10
Region: Providence
Article title: The Clinical and Radiographic Success of Bonded Resin Composite Strip Crowns for Primary Incisors
Author(s): Kupietzky, Ari DMD, MSc et al.
Journal: Pediatric Dentistry
Page #s: 577-581
Date: 2003 25:6
Major topic: Strip Crowns
Minor topic(s): NA
Type of Article: Retrospective Clinical Study
Main Purpose: The purpose of this study was to examine the clinical and radiographic success of the treatment of maxillary anterior primary incisors with composite resin strip crowns placed in a private practice setting.

Key points in the article discussion:

I. General:

A. Strip crowns (SC) have been used for over 2 decades and are the most esthetically pleasing form of full coverage anterior restorations.
B. SC's are also VERY "technique sensitive" (...which is the PC way of saying "it's easy to screw it up").
C. One recent study showed a "failure rate" of 51%

II. Methods:

A. 112 restorations placed in 40 children.
B. Evaluated after in place an average of 18mo.
C. 2 independent examiners.

III. Results:

A. NO restorations were lost and only 12% were rated as having lost some resin (88% overall retention rate!)
B. No difference if the crowns were placed 4 at a time vs fewer in a single sitting.
C. Pulpectomized teeth had more color matching discrepancies than non pulpectomized teeth.
D. 91% of the teeth demonstrated healthy pulps.
E. 8% demonstrated some pulpal changes but did not require immediate action.
F. Only one tooth demonstrated signs of pulpal necrosis.

IV. Conclustions:

A. SC's for restoring primary incisors with large or multisurface caries performed well.
B. Color match significantly reduced in pulp-treated teeth.
C. Bottom line?.... Kupietzky likey SC's

Assessment of article: As much as I tried to hate it... I actually like this article. I know I sometimes default to Nu-Smiles when really strip crowns would be a much better option. This is good info. Me Likey.

Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies

Resident: Adam J. Bottrill
Date: 27OCT10
Region: Providence
Article title: Two Case Reports of Complicated Permanent Crown Fractures Treated With Partial Pulpotomies
Author(s): McIntyre, Judy
Journal: Pediatric Dentistry
Page #s: 117-122
Date: Mar/Apr 2009, V31:No2
Major topic: Par
Minor topic(s): NA
Type of Article: Case Reports
Main Purpose: The purpose of this paper was to review scientific evidence supporting partial pulpotomy and its high success rate and illustrate the clinical technique by presenting 2 challenging cases of complicated crown fractures with long term follow-up.

Key points in the article discussion:

I. General:

A. Partial pulpotomy/vital pulp amputation/Cvek Pulpotomy, is a procedure that involves the surgical amputation of a TRAUMATICALLY EXPOSED pulp.
B. Dr. Cvek reported in 1978 that 96% of traumatically exposed pulps that were treated within 30 hours experienced "healing".
C. Procedure:
1. High speed with sterile diamond bur.
2. RDI
3. Saline rinse
4. Chlorhexidine antiseptic
5. 2 mm partial pulpotomy
6. CaOH placed on the NON-hemorrhaging pulp
7. Layer of ZOE
8. Final resin restoration.
9. MANY studies since then with varying results and techniques.

II. CASE REPORT #1

A. Healthy, 10yo, male, dental injury on swimming pool bottom, sheared-off maxillary centrals.
B. Nurse concluded his centrals had been "knocked out" and transported the fragments in milk to pedodontist... within 30 minutes (***immediate neuro screening***).
C. Exam and radiographs taken. No other significant injury other than fractured centrals.
D. Maxillary Centrals: non-hemorrhagic pulp exposures, no root fractures, PDL concussion, nearly closed apices.
E. Tx: 2-3 mm cvek pulpotomy, saline rinse, CaOH, GI cement, composite restoration.
F. Recc: soft diet, perfect OH, Tx options discussed.
G. 3wks: fractured segments re-bonded
H. Mouthgaurd delivered.
I. 3mo recare for a yr and then normal visits.
J. At 42 mo, no periapical pathology and normal vitality test responses.
K. SUCCESS! ... tooth vitality maintained and final closure of the root end obtained.
L. Ortho performed at 24 months with no adverse outcomes.
M. 2 uneventful debonds of the bonded fragments, but no other sequelae.

III. CASE REPORT #2

A. Healthy, 7yo, female, dental injury during archeological dig (totally normal activity for 7yo's), sheared-off maxillary centrals.
B. Dig was 5hr away from nearest civilization... 6.5 hours between trauma and dental care.
C. Exam performed and radiographs taken. No other significant intraoral injury other than fractured/SLIGHTLY mobile centrals. Unsure whether fracture extended sub-g or more apically toward the roots.
D. Same procedure as Case #1
E. Teeth continued to erupt normally and apices closed.
F. At 12 mo, fully erupted and complete restoration/seal placed.
G. At 24 mo, ortho.
H. By 60 mo, Rt central showed delayed response to cold. Increased pulp canal obliteration (PCO) evidence over the next several years.
I. Partial eruption made this case more difficult. Definitive sealing of the coronal pulp was delayed until full eruption.

Assessment of article: Quality write-ups... HOWEVER. I didn't really learn anything new.... "Medium Likey"

Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth

Resident: Adam J. Bottrill
Date: 20OCT10
Region: Providence
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Camp, Joe DDS MSD
Journal: Pediatric Dentistry
Page #s: 197-205
Date: May/Jun 2008, V30:No3
Major topic: Immature Tooth Vital Pulp Therapy
Minor topic(s): NA
Type of Article: Review of Literature
Main Purpose: Reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apezx. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.

Key points in the article discussion:

I. General:

A. Most of the diagnostic tests used used with endodontic therapy are of little to no value on primary teeth or immature permanent teeth.
B. Much of our Tx decisions are based on Dx of root development age... therefore it is necessary to have thorough knowledge of the rot development timeline for primary and permanent teeth.
1. Root formation is not completed for 1-4 years after eruption into the oral cavity.
C. Radiographs cannot accurately depict apical closure due to the development of canals in the lingual-facial direstion.
D. During formation and closure, Tx must be oriented at maintaining vitality and allowing the completion of root formation.

II. Dx of Pulpal Status in Primary Teeth.

A. Differentiation between provoked and spontaneous pain is vital.
1. Provoked: deep caries, faulty restorations, soreness around exfoliation and erupting permanent teeth.
2. Spontaneous: extensive degenerative changes extending into the root canals... should NOT receive vital pulp Tx. There may be other evidence of pulpal pathosis as well... mobility, fistula, percussive sensitivity etc...
B. ELECTRIC PULP TESTS ARE NOT VALID ON PRIMARY TEETH.
C. THERMAL TESTS ARE USUALLY NOT CONDUCTED ON PRIMARY TEETH.
D. Radiographic exam is necessary
1. Calcified masses are a sign of advanced pulpal degeneration... Pulpectomization or Extraction.
2. Internal resorption is also associated with extensive inflammation... Extraction.
3. Keep in mind the lucency of the succedaneous follicle.
4. Other obvious pathosis... fracture, abscess, bone fractures etc...
E. Excessive or oddly colored hemorrhage is evidence of excessive inflammation.
F. Studies have shown that trauma LIKELY will result in pulpal necrosis or at least pulpal obliteration (depending on degree of trauma, luxation, mobility etc...)
G. AVULSED PRIMARY TEETH SHOULD NOT BE REIMPLANTED.
H. About half of traumatized primary teeth will undergo discoloration.
1. Correlation of type of color change to pulpal health is controversial and inconclusive.

III. Diagnosis of Pulpal Status in Permanent Immature Teeth

A. Loss of pulp vitality before completion of root formation leaves the tooth MUCH more susceptible to root fracture.
B. Again, a history should be taken WRT history of trauma and type of pain etc...
C. Clinical and radiographic examination MOST important when diagnosing immature permanent teeth.
D. Electric pulp test and thermal test not reliable for immature, open apex teeth... also for children.
E. Electrical and Thermal tests unreliable for traumatized teeth.
F. Laser doppler flowmetry reportedly very reliable to diagnose pulpal vitality.
G. Discoloration also usually indicative of pulpal changes but not completely accurate.
H. There is MUCH better potential for an immature tooth to heal after trauma.
I. If doubtful of diagnosis, DO NOT start treatment. Attempt to allow formation of the root until definitive diagnosis can be made.
J. Lately, MTA and composite resins have been replacing CaOH, pulp cappng and pulpotomy.
K. Vital treatment of teeth with MTA, once considered taboo, is being used much more often in order to allow continued root formation.
L. Revascularization of necrotic pulps has even been reported using combinations of AB's.
M. And of course... he had to mention stem cells.

Assessment of article: Good Summary

Primary Molar Pulp Therapy - Histological Evaluation of Failure

Resident: Adam J. Bottrill
Date: 01OCT10
Region: Providence
Article title: Primary Molar Pulp Therapy - Histological Evaluation of Failure
Author(s):Waterhouse, P.J.
Journal: International Journal of Pediatric Dentistry
Page #s: 313-321
Year: 2000
Major topic: Primary Molar Pulp Therapy
Minor topic(s): NA
Type of Article: Analysis of extracted primary teeth with failed pulp therapy.
Main Purpose: Provide a qualitative comparison of the clinical, radiographic and histological outcomes in a small sample of cariously exposed primary molars, extracted after unsuccessful pulp treatment by two vital pulpotomy methods.

Key points in the article discussion:

I. General:

A. Primary molars extracted due to treatment failure during a longitudinal clinical investigation of the efficacy of formo (F) vs CaOH (C) powder.
1. 52 child patients (26m, 26f)
2. Randomly allocated to the formo or CaOH group.
3. Coronal pulp amputation recommended only in teeth with vital, cariously exposed pulp tissue.
4. 79 cariously-exposed primary molars were tx planned for pulp therapy.
a. 44 in F group... 35 in C group.
5. 6 Teeth were extracted... only 5 were intact enough for evaluation.

II. Results:

A. Both Groups...
1. Resorption of reactionary dentin
2. Dentin barrier formation
3. Root canal narrowing due to reactionary dentin formation
4. Pus cells

II. Conclusion:

A. Histological findings "may indicate possible reasons for treatment failure".

B. Clinical and radiographic findings "correlate well with the histological findings."

C. Recommendations:
1. Radiographic monitoring of teeth with pulp therapy is necessary. (Check!)
2. During coronal pulp amputation, if hemostasis can't be achieved tooth should be treated with pulpectomy or extraction (Really?!)
3. Restorations should be well-placed and monitored for signs of inadequate seal. (No kidding!!)

D. Allow me to translate... The conclusions and recommendations do not logically follow the title or purpose of the article. This paper hasn't provided any further insight on the difference between these two Tx modalities... I know, it sounds harsh, but I don't find this article particularly significant.

Assessment of article: SHE...NAN...I...GANS.

Management of avulsed Permanent Incisors: A decision analysis based on changing concepts

Resident: Adam J. Bottrill
Date: 17SEP10
Region: Providence
Article title: Management of avulsed Permanent Incisors: A decision analysis based on changing concepts
Author(s):Lee, Jessica DDS et al.
Journal: Pediatric Dentistry
Page #s: 357-360
Year: 23:3, 2001
Major topic: Avulsion injuries
Minor topic(s): NA
Type of Article: Analysis of avulsion injury management
Main Purpose: Provide a decision tree describing the management of avulsed incisors.

Key points in the article discussion:

I. General:

A. Reported incidence of avulsion 1-16% of all traumatic injuries. Maxillary central incisors most common

B. Age 8-12 most common permanent incisor avulsion.
1. loosely formed PDL provides minimal resistance to avulsion force.

C. Most common cause... fights and sports.

D. Treatment is aimed at minimizing the number of complications that occur
1. ankylosis, pulpal infection, PDL damage etc...

II. Management

A. THOROUGH HISTORY
1. Time Interval, conditions of avulsion, storage material

B. If decision is made to re-implant, RINSE with saline to remove visible debris... DO NOT SCRAPE DEBRIS OFF.

C. Teeth have been shown to survive from 20-40 yrs with normal periodontium. In other words... under the correct conditions, the tooth CAN be saved.

III. "New" Tx regimens

A. Topical AB's for enhanced revascularization

B. Hank's to preserve PDL

C. >1hr dry storage ... scrape off PDL, rinse and replant

D. Systemic AB's at time of reimplantation

Assessment of article: I like decision trees (...dork, I know). So this article is sans shenanigans in my book.