he Etiology and Prevalence of Ectopic Eruption of the Maxillary First Permanent Molar

Resident’s Name: Laura Randazzo Sabnani Date:3/27/2009

Article title:The Etiology and Prevalence of Ectopic Eruption of the Maxillary First Permanent Molar

Author(s): Pulver, Franklin

Journal: J. Dent for Children

Volume (number):

Month, Year:  March 1968

Major topic / Main purpose:  To determine the factors that influence ectopic eruption of the maxillary first permanent molar and to study the prevelance of ectopically erupting maxillary permanent first molars.  

Methods and Materials:  Children from the University of Michigan growth study, the department of pedodontics and orthodontics were used in the study.  Size of teeth, length of maxilla, calcification of teeth, eruption angle of the maxillary first permanent molar, time of eruption into occlusion, prevalence of the ectopic eruption, relative distribution of the ectopic eruption according to sex, quadrant, type, extend of resorption of second primary molar, and type of resulting occlusion, and related anomalies were studied.  

Result/Summary:  Out of 831 children 26 of them had 35 ectopic eruptions (3.1%).  There was no specific etiologic factor found to be common among all children.   It was found that there was larger than normal mean sizes of all maxillary primary and permanent teeth, larger affected first permanent molars and second primary molars, smaller maxillae, a more posterior position of the maxillae in relation to the cranial base, an abnormal angulation of eruption of the maxillary permanent first molar and a delayed calcification of some of the affected first permanent molars.  No sex difference or preference of sides was determined.  The severity of the ectopic eruption dictated the resulting occlusion and extend of resorption of the second primary molar.

Assessment of article:  Ok article.  Some interesting points to give to parents if they ask why their child has ectopic eruption.  

Ankylosis or primary molars: a future periodontal threat to the first permanent molar?

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Derek Banks Date: March 27, 2009
Article title: Ankylosis or primary molars: a future periodontal threat to the first permanent molar?
Author(s): J Kurol
Journal: Euro J Orthodontics
Volume (number): 13(5)
Month, Year: October 1991
Major topic: Eruption and Exfoliation
Minor topic(s): Ankylosis
Type of Article: part-retrospective study
Main Purpose: To determine if treatment modality (extract vs. let exfoliate) of infraoccluded primary second molars affects periodontal health of the first permanent molars
Overview of method of research: 68 subjects with history of ankylosed primary second molars. 57 had a follow-up (about 8 years later) clinical and radiographic exam. 11 had only a radiographic exam. Probing depths and bone levels were checked.
Findings: No significant periodontal defects were found in either group. In the extraction group 2 out of the 32 teeth had some bone loss, but normal periodontal probing depths. In the exfoliation group no appreciable bone loss or periodontal pockets were noted.
Key points/Summary : Do we really need to take out ankylosed primary second molars? From a strictly periodontal standpoint, not necessarily.
Assessment of article: Good article.

Relationship of Submerged Deciduous Molars to Root Resorption and Development of Permanent Successors

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Chad Abby Date: 2/20/2009
Article title: Relationship of Submerged Deciduous Molars to Root Resorption and Development of Permanent Successors
Author(s): S. Steigman, E. Koyoumdjisky-Kaye, and Y. Matrai
Journal: Journal of Dental Research
Volume (number): Vol 53, No. 1
Month, Year: January – February 1974
Major topic: Root resorption
Minor topic(s): relationship of submerged deciduous molars to root resorption and development of permanent successors
Type of Article: Clinical Study
Main Purpose: To determine whether submerged deciduous molars are a source of disturbance of the normal development of the permanent dentition and whether extraction is advocated.
Overview of method of research: Two-hundred seventy children (115 aged 4-6 years and 155 aged 7-10 years) with submerged, cariesfree deciduous molars participated in the study. A comparable sample of 270 children with normal, cariesfree deciduous molars served as a control. All deciduous molars with marginal ridges below those of the adjacent teeth were considered “submerged.” Root resorption was divided into six stages: no resorption, apex only, a third of the root, half of the root, two thirds of the root, and complete resorption of the root. In children with unilateral submerged molars, healthy contralateral teeth were used as controls.
Findings: No differences were found in the rate of root resorption between submerged and normal deciduous molars. The process of submerging in the deciduous molars did not delay the development of their permanent successors. Submerged deciduous molars should not be extracted unnecessarily.
Key points/Summary : It can be assumed that submerged teeth usually have no causative influence on the rate of development of their successors, and that the process of submerging should not be held responsible for retarded resorption of deciduous roots. Submerged teeth often exfoliate spontaneously in the normal age range. It was thought that submerged teeth should be extracted because they prevent the eruption of the succeeding permanent teeth. However, on the basis of this article a more conservative approach is suggested. Instead teeth need to be observed closely clinically and radiographically and only when it becomes obvious that resorption is not proceeding normally or that adverse occlusal changes are taking place, should extraction be considered.
Assessment of article: Good article, somewhat dated

Williams Syndrome

Literature Review Williams Syndrome Laura Randazzo Sabnani

Seen in 1/7500 births, present at birth, occurs in all ethnicities and effects males and females equally.
- Small upturned nose, long philtrum, wide mouth, full lips, small chin, puffiness around the eyes. Blue and green eyed children have a starburst ( a white lacy pattern on the iris)
- Most have heart or blood vessel problems such as narrowing of the aorta or pulmonary arteries, which can range from trival or severe, and cause an increased risk for high blood pressure.
- Young children can have elevated levels of blood calcium causing extreme irritability or colic-like symptoms
- Most children have low-birth weight and slow weight gain
- Feeding problems due to low muscle tone, severe gag reflex, poor suck/swallow, tactile defensiveness etc. May resolve as the children get older.
- Slightly small, widely spaced teeth are common. They also may have a variety of abnormalities of occlusion, tooth shape or appearance.
- Increased incidence of problems with kidney structure and/or function
- Inguinal (groin) and umbilical hernias are more common
- More sensitive hearing than other children; Certain frequencies or noise levels can be painful an/or startling, often this improves with age. (patient may be sensitive to the sound of the high speed) Young children often have low muscle tone and joint laxity. Joint stiffness may develop as children get older
- These children tend to have an excessively social personality. They are typically unafraid of strangers, extremely polite and show a greater interest in contact with adults than with their peers.
- Some degree of intellectual handicap. Young children with often experience developmental delays; milestones such as walking, talking and toilet training are often achieved somewhat later than is considered normal. Strengths and weaknesses are often seen in older children and adults. There are some intellectual areas (such as speech, long term memory, and social skills) in which performance is quite strong, while other intellectual areas (such as fine motor and spatial relations) are significantly deficient.
- Anesthesia concerns are the patient's cardiovascular system, kidney function, airway anatomy, metabolic status, joint mobility and level of cognitive functioning. “a cardiologic evaluation within the 12 months preceding surgery is desirable and records from the cardiologist should be requested for the anesthesiologists review. Copies of EKG'S, echocardiograms, chest x-rays (if available) and cardiac catheterizations (if appropriate) should be provided. The airway problems in WS concern the potential difficulty in placing an endotracheal tube for general anesthesia in the WS individual with an underdeveloped lower jaw. Dental problems, including brittle or loose teeth can compound this difficulty. These features are best noted when the anesthesiologist performs a brief, specific physical exam during the preoperative visit.”
www.williams-syndrome.org

Crouzon Syndrome

Significant craniofacial and/or oral features:
Lobed tongue
Hamartomas or lipomas of tongue
Cleft of hard or soft palate
Accessory gingival frenulae
Hypodontia
Ocular hypertelorism or telecanthus
Median cleft or pseudocleft upper lip
micrognathia

Etiology:
X-linked dominant genetic disorder and is mostly in females

Prevelene:
Estimates range from 1/50,000 to 1/250,000


Age of Diagnosis:
At birth in infants based on characteristic oral, facial, and digital anomalies, OR after polycystic kidney disease is identified in childhood

Factors that influence dental care or require dental intervention:
Treatment of cleft lip/palate, tongue nodules, accessory frenulae, removal of accessory teeth, and orthodontics for malocclusion
Speech therapy may be necessary


Associated systemic conditions:
Digital abnormalities
Brain abnormalities – intracerebral cysts, corpus callosum agenesis, cerebellar agenesis
Kidney – polycystic kidney disease
Mental retardation – usually mild
Skin and hair disorders such as alopecia

The teenagers reality

Resident’s Name: Brian Schmid Date: 9/19/08
Article title: The teenagers reality
Author(s): David Elkind PhD
Journal: Pediatric Dentistry
Volume (number): Vol. 9 #4
Month, Year: December 1987
Major topic: Theory of the “imaginary audience”, the ‘personal fable’ and how this affects a teenagers reality and actions
Minor topic(s: Applying these theories to increase compliance and put teenagers more at ease
Type of Article: Professional opinion
Main Purpose To encourage practitioners to assume the outlook of a teenager in order to better understand the motivation for their actions and inactions

Overview of method of research: Anecdotal

Findings: Becoming a teenager is now being accepted as the “second age of reason” in growing to adulthood, attaining the ability to form conceptual ideas about space and time as well as assuming the outlook of others. Since a teenagers experience is so vivid and engrossing to them, they assume that everyone, their own personal “imaginary audience”, is just as caught up in their self-obsession as they are. This construct has both positive and negative consequences; the audience can be a conscience keeping them from performing ill deeds that no one else may see. The audience also serves as a motivator for personal success. However, the need for acceptance by the imaginary audience can make young teenagers more susceptible to peer pressure, leading them to make rash and often injurious decisions. Teenagers also begin to develop the ‘personal fable’, which convinces the individual that bad things may happen to other people but not them; this delusion worsens their resistance to peer pressure. This personal fable also helps us deal with daily life without constantly worrying about our plane crashing or being struck by a wicked huge meteor. The fable also convinces the teenager that their experience is unique and could not possibly be understood by anyone else, least of all their parents who couldn’t be more unlike them. One of the most important inferences taken from these theories is that it is not lack of education which leads to bad decision making by teenagers, but rather we must wonder why teenagers disregard the consequences.

Key points/Summary : By applying the theories of the imaginary audience and the personal fable, we as health care professionals can at least attempt to assume the outlook of a teenager and better understand their motivations and actions. It does not help to fully accept or deny their suppositions but to put them to the test and let the teenager set the limits of their own audience.

Assessment of article: A clever theory attempting to border the mind of a risk-taking, self-obsessed teenager. Thinking in this way could help us increase compliance, for example wearing retainers or ortho rubber bands.

Rare Dental Abnormalities Seen in Occulo-Facio-Cardio-Dental (OFCD) Syndrome: Three Cases and Review of Nine Patients

Resident’s Name: Anna Haritos Date: October 3, 2008
Article title: Rare Dental Abnormalities Seen in Occulo-Facio-Cardio-Dental (OFCD) Syndrome: Three Cases and Review of Nine Patients
Author(s): Schulze et al.
Journal: American Journal of Medical Genetics
Volume (number): 82: 429-435
Month, Year: 1999
Major topic: characteristics of oculo-facio-cardio-dental syndrome
Minor topic(s): dental characteristics of OFCD syndrome
Type of Article: case report
Main Purpose: to highlight characteristics of this rare syndrome
Overview of method of research: presentation of three new cases of OFCD as well as review of 9 previous patient cases
Findings: OFCD syndrome has been confirmed only in female patients. X-linked dominant inheritance is most likely. All three cases discussed in this article presented with congenital cataracts and microphthalmia or microcornea. Two of the patients suffered from Atrial septal defect. All of the three patients had clefting of the hard and soft palate. Of the 9 reviewed patients and 3 new cases presented, 50% of the 12 patients were affected with clefting. The most important criteria leading to diagnosis of OFCD syndrom are dental abnormalities, specifically extreme elongation of the canine roots. All patients have radiculomegaly of the canines. Radiculomegaly also present in permanent incisors and premolars in some instances as well. Delayed eruption of deciduous and permanent teeth is also a distinctive characteristic of OFCD syndrome and is present in most patients.
Key points/Summary:
O – ocular anomalies: congenital cataract, secondary glaucoma and microphthalmia
F – facial appearance; narrow face, high nasal bridge, broadening of the nasal tip with separated cartilages, cleft palate or submucosous cleft palate
C – cardiac anomalies; atrial septal defect, ventricular septal defect
D – dental; radiculomegaly of canines, oligodontia, delayed dentition, retained deciduous teeth, hypodontia
Syndactyly of toes 2-3 and partial hearing loss also described;
intelligence can range from normal to retarded
Assessment of article: very clear; highlights the central role of dental anomalies in this rare syndrome

Pretreatment Modeling: A Technique for Reducing Children’s Fear in the Dental Operatory

Joanne Lewis
Date: 9-12-08

Article title: Pretreatment Modeling: A Technique for Reducing Children’s Fear in the Dental Operatory
Author(s): Paul E. Greenbaum, Ph.D.; Barbara G. Melamed, Ph.D.
Journal: Dental Clinics of North America
Volume (number): 32
Month, Year: October 1988
Major topics: The use of modeling as a pretreatment preparation to reduce children’s fear and misbehavior during dental treatment.
Minor topics: N/A
Type of Article: Review of research
Main Purpose: Present and summarize the research regarding modeling as a behavior guidance technique; includes advice on implementation of modeling in a dental practice.
Overview of method of research: Review of research
Findings: This article seeks to answer several questions:
How well does modeling work?
Children who were exposed to modeling (watched an older sibling receive dental treatment) had more positive behavior during treatment, for both a cleaning and exam and for a restorative appointment. Yes, modeling can reduce patient fear associated with treatment.
Does the child’s age or gender affect the effectiveness of modeling?
According to the research, modeling has been shown to reduce fear behavior among male and female children and across a wide age range – 3 to 13 years of age.
Does the child’s fear level affect the effectiveness of modeling?
The research shows that modeling reduces patient fear in both high and mild to moderate fear level children.
Is modeling more effective on children with previous dental experience or on children with no previous dental experience?
Modeling preparation by itself is more effective on children with no previous dental experience. However, modeling in combination with other techniques (coping instructions, imagery, etc.) may be effective in children with previous dental experience.
What behavior should be modeled?
2 components – 1.) the child must vicariously receive rewards, either the model receives reinforcement or the model does not receive any adverse consequences and 2.) the child must be presented with information about the upcoming dental treatment and how to handle it.
Should the model be highly similar to the patient, or of high prestige?
Both similar and high status models can be effective.
Is a symbolic model as effective as a live model? – YES!
Should mothers (parents) be allowed in the operatory during dental treatment?
Mothers often act as a natural model for their children’s behavior. The parent is an important model in children’s ability to cope with stress.
Key points/Summary :
Modeling is an effective behavior management technique to reduce fears and decrease disruption, especially in patients with no prior dental exposure. Many practitioners do not currently use modeling; in the past, it was a difficult technique to implement. Now with videos and DVD’s, modeling could gain more widespread use, especially if a set of standardized modeling tapes was developed.
Assessment of article:
A good reminder of a behavior guidance technique that is familiar and intuitive – really, just an expansion on tell-show-do. Makes a good case to increase the use of modeling in the pediatric dental office.

FETAL ALCOHOL SYNDROME

Resident’s Name: Joanne Lewis Date: October 10, 2008

FETAL ALCOHOL SYNDROME
What is affected in the syndrome?
• Growth deficiency
• Facial features – three diagnostically significant features:
o Smooth philtrum
o Thin upper lip
o Small palpebral fissures – decreased eye width
(note: these facial features strongly correlate with brain damage)
• Central nervous system damage
o Structural abnormalities of the brain – microcephaly
o Neurological impairments – seizure disorders, poor hand-eye coordination, poor fine motor skills
o Functional impairments – learning disabilities, poor impulse control, poor judgment, attention and hyperactivity problems (ADHD), poor social skills, mental retardation
• Heart murmur by 1 year of age
• Joint anomolies, small distal phalanges
• Renal problems – horseshoe, aplastic, or dysplastic kidney
• Decreased visual acuity
• Secondary disabilities
o Mental health problems
o Disrupted school experience
o Trouble with the law
o Confinement
o Inappropriate sexual behavior
o Alcohol and drug problems
How? Fetal alcohol exposure is the leading known cause of mental retardation in the Western world, with a prevalence rate of 0.2 to 2.0 cases per 1,000 live births. There is no clear consensus as to what level of exposure is toxic.
How is the diagnosis made? Criteria for a FAS diagnosis are:
• Growth deficiency – prenatal or postnatal height or weight at or below the 10th percentile
• All three FAS facial features present
• Central nervous system damage
• Prenatal alcohol exposure

Why are we interested? The first step in the management of a dental patient with FAS is recognition of the condition. This is best accomplished via the medical history and open discussion with the patient or family members. Once a patient with FAS is identified, the dental practitioner must learn as much as possible about the history of the patient, including type and extent of systemic manifestations and any current medications. Dental treatment will have to take into account:
• Consultation with physician to determine if the patient needs antibiotics prior to dental treatment due to heart murmur
• Behavior problems
• Orofacial manifestations including cleft lip/palate, dental malocclusions, poor muscular tone around the mouth (excessive drooling), deficient maxilla or mandible
• The ability of the patient to metabolize medications


Items of interest: Many patients with FAS have sensory integration dysfunction, a neurological condition that causes sights, sounds, and physical sensations to be over or under exaggerated. Think about the dental office!

Ethical issues in managing the noncompliant child

Resident’s Name: Chad Abby Date: 9/19/2008
Article title: Ethical issues in managing the noncompliant child
Author(s): Ann L. Griffen, Lawrence J. Schneiderman
Journal: Pediatric Dentistry
Volume (number): Volume 14, Number 3
Month, Year: May/June 1992
Major topic: Behavior Management
Minor topic(s): ethical issues in behavior management techniques
Type of Article: Case review
Main Purpose: How best to handle patients who refuse dental treatment.
Overview of method of research: To help answer the question for behavior management interventions five areas of consideration were analyzed – the indications for treatment, patient autonomy, the benefits of dental treatment versus the burdens of a management intervention, the desires of parents, and external factors such as allocation of resources. Cases were presented and appropriate action discussed.
Findings: Children are not granted the legal autonomy, or right to refuse or consent to treatment (under 18) because they may not be competent to act in their own best interests. However, we need to seek the child’s assent to treatment in combination with permission of the parent or guardian. Assent asks that pediatricians involve children to participate in making decisions about their health and health care to the extent that they are able. Studies have shown that children under the age of seven have very little capacity to appreciate the consequences of treatment options. The estimation of capacity and determination of level of involvement in decision making lie within the judgment of the health professional. When deciding to use a management technique, the associated risks must be assessed. 1 in 10,000 of all anesthetized patients die of causes primarily attributal to anesthesia, although the risk to healthy patients is considerably lower. This risk is less than that of one year of normal automobile travel during which death rates are 2 in 10,000 persons. If parents refuse all reasonable treatment options offered, the dentist is obligated to attempt to educate to overcome ungrounded fears or misapprehensions. In cases of failure to obtain needed dental treatment, the dentist may be obligated to report the neglect to the appropriate agency to protect the child. At times economic factors may limit the use of general anesthesia for many patients, often those who need it most. The dentist’s obligation is to the patient, and considerations of public expense and attempts to ration or allocate scarce or limited resources ideally should be dealt with at a policy-making level and should not enter into individual treatment decisions.
Key points/Summary: Patient autonomy, or the right of self-determination, including the right to refuse treatment, is a fundamental right of all competent patients. Often as pediatric dentists we need to make this choice for the child because they may be incapable of appreciating the consequences of their choices. The following areas should be considered ethical decision making when a patient refuses treatment: Indications-carefully reconsider the urgency of the dental needs and determine if treatment can be delayed or avoided with no lasting ill effects; Assent- estimate the capacity of the child to participate in decision making, and involve the child to the extent of that capacity; Benefits versus burdens- determine what management techniques are likely to make treatment possible in a given situation; Permission- obtain parents’ permission after presenting a description of the recommended techniques, alternatives, and an assessment of the risks associated with refusing treatment; External factors- pediatric dentists have a responsibility to attempt to shape policy to make care more available on the basis of need as part of an overall system of justly distributed health care.
Assessment of article: Great article to review once in a while