12/22/2010 Delayed tooth eruption associated with an ameloblastic fibro-odontoma (AF-O)

Resident: J. Hencler
Date: 12/22/2010

Article title: Delayed tooth eruption associated with an ameloblastic fibro-odontoma (AF-O)
Author: Flaitz DDS, MS; Hicks MD, DDS, MS, PhD

Journal: Pediatric Dentistry-23:3, 2001
Major topic: Oral Pathology
Type of Article: Case Report

Main Purpose:
Describe the clinical and radiographic features of an AF-O in a young child and discuss an age appropriate differential diagnosis.

Case History:
A healthy, 31 month-old Hispanic boy was referred for evaluation of an unerupted left mandibular primary canine (#M). EOE revealed mild facial asymmetry of the lower1/3. IOE revealed both buccal and lingual cortical expansion of the left mandible with lingual displacement of the lateral incisor and distal displacement of the molars. Palpation revealed an asymptomatic, hard enlargement covered by normal mucosa. A periapical radiograph demonstrated a localized radioluceny with dilacerations of the mesial root of the primary first molar and posterior displacement of the developing premolar. An occlusal radiograph reveals an expansile, mixed radiolucent/radiopaque lesion surrounding the crown of an inferiorly displaced, unerupted canine. Based on these findings, the child was referred for surgical excision under GA. Histopathological finding included a tumor with cords/islands of odontogenic epithelium, conglomerate foci of enamel and dentin, and tiny tooth-like structures. Loose and cellular connective tissue stroma resembled a dental papilla and a well formed primary canine was associated with the tumor. A diagnosis of AF-O was made on these microscopic findings.

Key points in the article discussion:
The AF-O is an uncommon odontogenic tumor that resembles an ameloblastic fibroma and a complex odontoma. Most cases occur in children with a mean age between 8-11 years-old but cases as young as 9 months have been reported. AF-O occurs equally in both jaws but favors the anterior region in the maxilla and the posterior region in the mandible. Typically, a slow growing tumor, common clinical findings include painless swelling and failure of one or more teeth to erupt. Radiographic presentation varies from unilocular to multilocular radiolucency with well-defined margins and variable amounts of radiopaque material. The irregular or globular calcifications are usually located in the center of the lesion. Treatment of AF-O usually involves conservative curettage. Large lesions may require a surgical splint to prevent jaw fracture. Recurrences following conservative surgery are uncommon and the prognosis is excellent for this tumor.

Differential Diagnosis:
Other odontogenis lesions in children that present as radiolucent lesions with irregularto globular radiopacities include the adenomatoid odontogenic tumor (AOT), the calcifying odontogenic cyst (COC), and the complex odontoma.
(1) The complex odontoma is the most common and usually occurs in the first 2 decades of life. Considered to be a developmental anomaly or hamartoma the complex odontoma has a predilection for the pericoronal molar region. Most odontomas are asymptomatic and are diagnosed because of delayed eruption of a tooth. A developing odontoma may be difficult to distinguish from an AF-O, both radiographically and microscopically. An important difference between an odontoma and AF-O is that odontoma is smaller and minimally expansile. Local curettage is recommended treatment and recurrence is rare.
(2) AOT occurs predominantly in children during the 2nd decade with delayed tooth eruption as a symptom. This benign tumor has a distinct preference for the anterior jaws, in particular, the maxillary canine region. Many AOTs are small and don’t produce clinically significant distortion of the surrounding bone. AOTs typically present as a well-delineated, unilocular radiolucency around the crown of a developing tooth with fine flecks of calcification referred to as a “snowflake appearance”. EXT of involved tooth and enucleation of the tumor are the recommended treatment. Recurrences are rare.
(3) COC is an uncommon lesion that exhibits variable clinical presentation. Although cystic, benign and malignant neoplastic subtypes are defines. When COC occurs in young children, the cystic type is most common and usually associated with an odontoma. This cystic lesion usually occurs in the anterior region of the jaws with a peak incidence in the second and third decades. Radiographic features of COC include a unilocular or multilocular radiolucency that is associated with an unerupted tooth in 1/3 of cases. Approximately half of all COCs are associated with irregular or tooth-like opacities; however, if associated with an odontoma, calcifications are a constant feature. Asymptomatic expansion of the cortical bone, along with root resorption or divergence may be seen. In general, COC occurring in young children are treated by simple enucleation with uncommon recurrence.

Assessment of article: Very interesting case report including a detailed differential diagnosis. This was a good review of oral lesions that we should consider when a patient presents with an unerupted primary tooth.

12/15/2010 Retention of Veneered SSCs on Replicated Typodont Primary Incisors: An In Vitro Study

Resident: J. Hencler
Date: 12/15/2010

Article title: Retention of Veneered SSCs on Replicated Typodont Primary Incisors: An In Vitro Study
Source: Pediatric Dentistry-25:3, 2003
Author: Guelmann et al.
Major topic: Retention of veneered SSCs
Type of Article: Scientific
Main Purpose: To determine the effect of crimping and cementation on retention veneered SSCs.

Overview of method of research:
120 crowns (90 nusmile) and (30 plain) were assessed for retention. An ortho wire was soldered perpendicular to the incisal edge and the crowns were fitted to acrylic replicas of ideal crown preps and were divided into 3 grps. Grp 1 crown crimp only, grp 2 crown cemented only, and grp 3 crowns crimped and cemented. An Instron machine recorded the amount of force necessary to dislodge the crowns.

Findings:
Grp 3 was statistically more retentive than grps 1 or 2 and Grp 2 was statistically more retentive than grp 1. In grp 1, Unitek crowns were more retentive than veneered crowns. In grp 2, NuSmile crowns showed less retention than all other brands, and in grp 3, Kinder Krowns showed better retention than all other brands.

Key points in the article discussion:
This study confirmed other reports that SSC retention is largely dependent on cement and demonstrated the beneficial effects of crimping in conjunction w/ cementation. Unitek crowns were more retentive in the “crimping only” grp as a direct result of the “snug fit” obtained from the internal walls of the crown being in direct contact w/ the tooth. The Dura Crown manufacturer clains crimping on both facial and lingual is possible w/out compromising the veneer integrity but this study found it was a challenge to crimp the facial margin w/out damaging the facings in some way. Kinder Krowns allowed crimping on the lingual surface only. These crowns are designed with an “incisal lock” technology to provide additional retention of the esthetic facings by mechanically forcing a portion of the facing material through openings on the incisofacial edge to the internal aspect of the crown. This prevented the Kinder Krowns from fully seating on the ideal tooth prep used in this study. Significant metal-cement bond failure for NuSmile primary crowns in the cementation only grp was difficult to explain. The use of natural teeth and a different luting cement may have a different impact on the results of this study.

Summary of conclusions:
Crimping does have a significant effect on retention of SSCs to acrylic replicas of primary teeth. The presence of cement significantly improved crown retention. Higher retention values were obtained for all brands tested when crimping and cement were combined. Crowns w/ veneer facings were significantly more retentive than the no-veneer (Unitek) crowns when cement and crimp were combined.

Assessment of article: Good article, nothing groundbreaking.

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?

The influence of medical history on restorative procedure failure rates following dental rehabilitation

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: The influence of medical history on restorative procedure failure rates following dental rehabilitation.

Author(s): Ng et al.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2001. 23:6. 487-490.

Overview of method of research: Scientific Article

Purpose:
To evaluate the relationship between patient medical history and success of restorative treatments performed under general anesthesia.

Methods:
Dental records of 504 patients who received comprehensive dental treatment under general anesthesia at either Children’s Hospital in Boston (1990-1992) or Children’s National Medical Center in DC (1994-1998) were reviewed. All treatment was performed by pediatric dental residents under the supervision of attending. Only patients who returned at least 6 months after treatment for follow-up were used in the study (241 patients). Failure was defined as need for restoration replacement due to structural breakdown (including perforation of SSCs due to wear-through), pulpal/dentoalveolar infection or recurrent decay.
Patients were grouped into 2 different categories: healthy or having a significant medical history (having a classified developmental disability, asthma requiring chronic meds, bleeding disorders, cancer, cleft lip/palate, diabetes, endocrine disorders, GI/liver disease, heart disease requiring meds, HIV infection, kidney disease, seizure disorder, sickle cell disease or any syndrome). Patients were also categorized as having a developmental disability (autism, cerebral palsy, emotional disability, learning disability or mental retardation) or having no developmental disability.
In addition, a subgroup of records was reviewed to determine the association between medical history and failure of restorations placed on patients in full primary dentition (FPD) (206 patients).

Findings for patients in FPD:
Amalgam restorations had a significantly higher failure rate than SSCs and the highest failure rates were found in composite restorations.
Although there was a slightly higher failure rate of restorations in patients with significant medical histories that healthy patients, the only statistically significant finding was a 16% failure rate of SSCs in patients with developmental disabilities compared to a 7% failure rate in patients without disabilities. It was reported that the majority of the failures in patients with developmental disabilities was due to excessive occlusal wear leading to perforation.
There were no significant differences found in amalgam or composite failure rates in patients with or without significant medical histories or developmental disabilities. There was also no statistical difference when comparing DC and Boston patients.

Key points/Summary:
1. SSCs are the most reliable restorations for primary teeth in patients treated under GA with amalgam restorations being slightly less reliable and composite restorations including strip crowns the least reliable.
2. Amalgam and composite restorations have similar failure rates in patients with or without significant medical histories or developmental disabilities.
3. SSC failures are more likely to occur in patients with developmental disabilities, but not necessarily significant medical histories than healthy patients.
4. SSC failure rates in patients with developmental disabilities were similar to that of amalgam restorations.

Assessment of Article:
I am not sure why they only evaluated patients in the subgroup (FPD) rather than all patients who were present for follow-up appointments. Nevertheless, these were interesting findings that I will keep in the back of my mind as I am treatment planning.

The Use of umalgam in pediatric dentistry: review of the literature

Resident: Swan

Article Title: The Use of Dental Amalgam in Pediatric Dentistry: Review of the Literature

Author: Osborne, et al.

Journal: Pediatric Dentistry

Volume (Number): 24:5 2002

Major Topic: Amalgam use in Primary and Permanent teeth

Type of Article: Literature Review

Main Purpose: Confirm the use of amalgam as a safe, long-lasting, cost-efficient restorative material

Key Points/Summary: The authors presented a brief history of amalgam as a restorative material, detailing the advent of the current high-copper amalgams which exhibit much less corrosion and porosity than earlier amalgams.

Use of Amalgam in Primary Teeth: The authors conclude that while amalgams perform very well in primary teeth, recent material improvements in both resin based composites and RMGI cements have made them very attractive restorative options as well. It was interesting to me that in their lit review promoting the use of amalgam, one of the principal studies cited was a clinical trial that found a 9% failure rate of amalgam restorations, an 8% failure rate of GI restorations, and a 7% failure rate for RMGI restorations. Obviously, tooth colored restorations are achieving clinical success. The authors point out that amalgam is a good restorative option when isolation or patient cooperation is difficult.

Conservative Dentistry: In a 10 year study comparing traditional amalgam restorations through occlusal fissures to resin composite restorations, the two performed equally as well. However, when the traditional amalgam and resin composite restorations were compared with amalgam restorations placed only where carious dentin had been removed, then remaining fissures sealed, the latter restoration performed much better (2% failure rate over 10 years compared to 17% failure and 14% failure for traditional amalgam and composite, respectively.

Amalgam safety: The authors cited 24 studies that confirm amalgam’s safety. One study showed that for every 12 amalgam restorations in the mouth, the rate of release of mercury is 1.7 micrograms per day, or 10% of the daily intake of mercury from all sources (air, water, diet). This is less than .2% of the toxic level.

Assessment of Article: Thorough, well-researched lit review that concludes what we all know to be true: amalgam is a good thing.

The use of amalgam in pediatric dentistry

Resident: Cho

Author(s): Fuks, Anna.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2002. 24. 448-455.

Major topic: Amalgam

Type of Article: Position Paper

Main Purpose: This report summarizes the several factors regarding amalgam restorations, including the material itself, the operator, and the patient.

Key points/Summary:

Factors related to the material:

- Toxicity of amalgam:

All estimates of daily total amalgam-associated mercury intakes are well below threshold for hazard to health. One human study demonstrated that the correlation between mercury levels in the mother and the newborn child was more closely related to the amount of fish consumed than to the number of amalgam fillings in the mother. True allergies to amalgam are rare, though there have been reports of an associated oral lichenoid lesion adjacent to amalgam restorations on rare occasion.

- Marginal integrity:

Amalgam is the only restoration nowadays in which the marginal seal improves with time. This is due to the acid environment and the low oxygen concentration in the space between the tooth and the restoration, leading to corrosion.

Factors related to the patient:

A disadvantage of amalgam is that it is unsuitable for minimal carious lesions. Studies have reported that the lifespan of SSC’s were twice that of amalgam for children age 4 years of age and younger. If the carious lesion is extensive and/or in more than 2 surfaces, a SSC would be indicated even for children older than 4 years of age.

Factors related to the operator:

Amalgam tends to be much less technique sensitive and more operator friendly compared to other restorative materials.

Recommendations for amalgam:

1. Class I restorations in primary and permanent teeth

2. Two surface Class II restorations where prep does not extend beyond proximal line angles

3. Class II restorations in permanent molars and premolars

4. Class V restorations in primary and permanent posterior teeth

Assessment of Article: Good summary of why amalgam is a great restoration!

Extent of Tooth Decay in the Mouth and Increased Need for Replacement of Dental Restorations: The New England Children’s Amalgam Trial (NECAT)

Resident: J. Hencler
Date: 12/08/2010

Article title: Extent of Tooth Decay in the Mouth and Increased Need for Replacement of Dental restorations: The New England Children’s Amalgam Trial (NECAT)

Author: Trachtenberg et al.
Journal: Pediatric Dentistry V30/No 5 Sept/Oct 08
Major topic: Factors contributing to restoration replacement

Main Purpose:
Investigate the association b/t the rate of restoration replacement and the number of dfs/dft and DFS/DFT at the time of restoration placement.

Overview of method of research:
Data was collected as part of the NECAT. Children b/w 6-10 years old were eligible if they had no existing amalgams and 2 or more posterior teeth w/ caries requiring occlusal restorations. 534 children were included in the study and randomized to receive either amalgam or composite/compomer restorations. Follow up was completed every 6 months for a five-year period. If a restoration required replacement, the reason was categorized as one of the following: 1) new caries; 2) recurrent caries; 3) fracture; 4) restoration loss; 5) other.

Findings:
Over the 5-year trial, 3,604 restorations with follow-up were placed in 489 children. Median dfs/DFS and dft/DFT were 15 and 8, respectively. Over the entire study, 212 of restorations required replacement due to new caries on adjacent tooth surfaces or recurrent caries. Of these, 69 were in primary teeth and 143 in permanent teeth.

Key points in the article discussion:
It is clear that the need for replacement increased with decay in the mouth. In terms of predicting the need for replacement, the number of dft/DFT rather than surfaces, was the better measure and found to be significantly related to replacement rates. Replacement rates were higher for increasing numbers of dft/DFT. The need for replacement also increased with age, was higher in posterior teeth compared to anterior teeth, and was significantly higher for composite and compomer restorations than amalgam. This paper presents for the first time analyses to investigate the increasing need for restoration replacement due to decay in the mouth. Although this association has been common knowledge among dental practitioners, there have been no prior studies to substantiate this consensus, nor any data to provide info to dentists and patients about the likelihood of replacement. Parents should be informed that dental restorations are susceptible to failure and that this failure may be preventable in the same way that tooth decay is preventable with modifications in OH and diet.

Summary of conclusions:
Children w/ high rates of caries are at higher risk for replacement of restorations. Patients should be informed that dental restorations are susceptible to failure due to factors related to tooth decay such as bacteria, diet, and poor OH.

Assessment of article: Good study.
It quantified what we already know; that high caries risk is related to increased restoration replacement.

Long-term Photographic and Radiographic Assessment of Bonded Resin Composite Strip Crowns for Primary Incisors: Results After 3 Years

Resident: Roberts

Date: 12/8/10

Article title: Long-term Photographic and Radiographic Assessment of Bonded Resin Composite Strip Crowns for Primary Incisors: Results After 3 Years

Author: Kupietzky, Ari

Journal: Pediatric Dentistry

Volume: 27: 3

Year: 2005

Purpose

The aim of this study was to examine the photographic and radiographic success of the treatment fo maxillary anterior primary incisors with composite resin strip crowns placed in a private-practice setting after a minimum of 18 months.

Methods and Results: 145 restorations, placed in 52 children, were evaluated by two independent pediatric dentist. Radiographs and photographs were used to evaluate the results. The average time of evaluation was 31.3 months after initial placement of the resin crown. None of the restorations were totally lost. 20% of the restoration showed some form of lost resin material, resulting in an overall 80% retention rate. 92% of teeth indicated healthy pulps, 6% had signs of change but did not require immediate attention( changes noted included: prematrure resorption, calcific metamorphosis and internal resorption) Only 2 teeth showed signs of radiographic evidence of pulpal pathology that required immediate treatment.

Conclusion:

Strip crowns are an excellent choice for teeth that present with multisurface caries. The long term prognosis has a high degree of predictibility and esthetics are unparallelled by other similar restorations. With these results, clinicians should be more apt to choose strip crowns over some of the other more expensive and less esthetic options.

Clinical Evaluation of a Compomer and an Amalgam in Primary Teeth C lass II Restorations: A 2 year Comparative Study

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Clinical Evaluation of a Compomer and an Amalgam in Primary Teeth C lass II Restorations: A 2 year Comparative Study
Author(s): Katerina Kavvadia, DDS, MDent Sc, Dr Odont. Et al
Journal: Pediatric Dentistry
Year. Volume (number). Page #’s: 2004. Vol 26 no 3. 245-251
Major topic: The purpose of this study was to compare the clinical performance between the compomer f2000 and amalgam Dispersalloy in class II restorations in primary molars over a 2 year period.

Overview of method of research: 75 amalgam and 75 comps were placed in 75 children in two separate pediatric dentistry private practices. In each child, an amalgam and a composite were placed in contra-lateral sides. The restorations were evaluated at 1 week, and then 6, 12, and 24 months by two independent calibrated evaluators. The rests were evaluated clinically, radiographically (bitewings), and under scanning electron microscope. The clinical exams were performed according to the Ryge criteria, including
1. Retention, bulk fracture, and presence (or not) of secondary caries. Ranked as either Yes or NO
2. Surface texture, marginal adaptation, marginal discoloration, contact area, and anatomic form. Ranked as either Alpha (ideal), Bravo (Acceptable) or Charlie (Unacceptable).

Findings:
Clinically
One amalgam was lost, and one comp had secondary caries. No bulk fractures in either group. None graded as “Charlie”. Many comps. Were rated as “Bravo”, while many Amals. Were rated as “Alpha”.

Radiographically
Five Amals and four Comps had cervical defects. These defects did not progress after 24 months.

SEM
Amals demonstrated marginal microfractures leading to ditching, leading to loss of anatomic form. Comps exhibited generalized wear, leading to loss of anatomic form and exposure of the cavity walls (although no marginal integrity was lost).

Key points/Summary:
Eventhough comps exhibited significantly higher “Bravo” scores regarding marginal adaptation and anatomic form, there is not an increased risk for secondary caries and failures… over a 2 year period!

Assessment of Article: Good article, Skeptical about how they continually reviewd how amazing the results were, and how awesome the comps were, but then quietly mentioned it was only with regards to the 2 year time frame. Shenanigans? Maybe.

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.