May 31, 2012 Original Rel.: May 2012 Termination: May 2014

™ presents Vol. 26 No. 1

in Pediatric Dentistry Literature review and critical analysis from the publisher of Practical Reviews Dialogue Filling in the Gaps: POWER Program

A Continuing Dental Because children tend to see dentists more than any other doctor, it is Education Program Endorsed by the American Academy of important for you to provide them with resources and activities to Pediatric Dentistry combat childhood obesity E-quiz code: 31885N By Amanda E. Garant, BS, MS s you are well aware, there are many The POWER program was established in IssueHighlights health consequences related to child - October of 2008 and has grown tremen - hood obesity, including coronary dously since its inception. POWER has had hAeart disease, stroke, hypertension, type 2 about 2,500 referrals, and we have seen These articles have diabetes, cancer, high total cholesterol, liver over 1,000 patients. As we have continued been selected by the and gallbladder disease, sleep apnea, res - to grow, we realized the need for all health Coordinating Editor as Key Reviews. piratory problems and even professionals to work health complications including together to reduce this Critical Discussion infertility and mental health con - With any change, the entire epidemic of childhood and Commentary ditions. Most of these disease obesity. Approximately Toothaches & Cavities Both states were perceived as adult- one-third of our chil - Affect Children’s Well-Being family needs to be on board. onset disease states, but we dren and adolescents pa ge 3 are seeing more and more of We have found children hav - are obese or over - Do Not Rinse AfterTooth them in our children in the Pedi - weight, and this num - • Brushing atric Overweight Education and ing little to no success when ber has tripled since Research (POWER) program at 1980. Another com - pa ge 4 Riley Hospital for Children in In - parents do not get involved. mon trend that we see AreYou Using Medications dianapolis, Indiana, where I am is Hispanic boys age for Children Without FDA a registered dietician. For ex - two to 19 years are Approval? ample, sleep issues are so common now significantly more likely to be obese than pa ge 5 that most of our patients are scheduled for non-Hispanic Caucasian males, and non- more… a sleep study right after their initial assess - Hispanic African-American females were ment. So why is obesity becoming and con - significantly more likely to be obese than Literature Reviews tinuing to be such a concern with our are non-Hispanic Caucasian females. youth? The list could go on and on, but What Kinds of Oral Appliances Best Manage many common issues we see are the in - The POWER program is a multidisciplinary, Sleep Apnea? creased amount of sweetened beverages multi-pronged obesity program. We try as a consumed, that people are eating out and team to fight obesity from all directions. Our page 6 choosing processed foods, they are making team includes a registered dietician, a phys - • Child Abuse Is Not Associ - poor snack choices, they are skipping ical therapist, a psychologist and then our ated With Later Obesity meals, they lack variety in the diet, they medical team including a doctor or nurse page 8 have little to no activity, there is an in - practitioner. Our program is a six-month creased amount of screen time including program. At the initial appointment, families • Does Coffee for Mom Mean a Restless Sleep for Baby? video games and texting, and they are eat - will meet with all providers on the team for a ing little to no fruits or vegetables. As our one-on-one visit and initial assessment. page 13 program works together, we have three After the initial assessment, they will rotate more… main missions — promote healthy lifestyles through each provider every one to two in children with obesity, advance education weeks until they have seen everybody at Practice Quiz in the field of pediatric obesity and foster re - least two times. When they have completed page 14 search in pediatric obesity. We feel the this first phase, patients move on to the more healthcare providers that are on board follow-up phase, which consists of monthly with fighting this battle, the better chance evening group sessions. The family will we will have to make the new generation have a final appointment with a member of the healthy generation. the medical staff before completion.

1 As you will realize, I continue to say family rather than child . ™ presents With any change, the entire family needs to be on board. We have found children having little to no success when parents in Pediatric Dentistry do not get involved. Our success stories almost always have Literature review and critical analysis from the publisher of Practical Reviews at least one family member committed to helping. This is im - portant when you discuss any medical health change for a Coordinating Editor Rebecca L. Slayton, DDS, PhD Arthur J. Nowak, DMD Diplomate, American Board of child. Get the family involved as much as you can. To meas - Diplomate, American Board of Pediatric Dentistry Pediatric Dentistry Professor and Chair, Pediatric ure the success, we use three different methods: Families Professor Emeritus of Pediatric Dentistry Dentistry and Pediatrics University of Iowa College of are assisted with reaching healthy goals pertaining to physi - University of Iowa Dentistry cal fitness, eating habits, weight and improvement in medical Iowa City, IA Iowa City, IA conditions. We also have families use pedometers and jour - Reviewers S. Thikkurissy, DDS, MS Joel Berg, DDS Diplomate, American Board of naling to track their physical activity and nutrition. And at Diplomate, American Board of Pediatric Dentistry Pediatric Dentistry Assistant Professor each clinical visit we obtain height, weight and body mass Professor, Lloyd and Kay Chapman Section of Pediatric Dentistry Chair for Oral Health The Ohio State University College index (BMI). University of Washington of Dentistry, Pediatric Dentistry Department of Pediatric Dentistry Columbus, OH Seattle, WA Common Obstacles Erwin G. Turner, DMD Michael J. Casas, DDS, MSc, Diplomate, American Board of Since children and families see the dentist on a regular basis FRCD(C) Pediatric Dentistry Staff Pediatric Dentist Professor, Division Pediatric far more times than they see any other healthcare provider, it The Hospital for Sick Children Dentistry Associate Professor Cincinnati Children’s Hospital is important for you to understand how you can help and un - University of Toronto Medical Center Consultant Division of Pediatric Dentistry derstand the obstacles you might face. Obstacles we see in - Departments of Dentistry and Cincinnati, OH Research cludes the family’s readiness to change. Unfortunately, you Bloorview MacMillan Children’s Paul O. Walker, DDS, MS cannot make the changes for them. They have to want to Center Diplomate, American Board of Toronto, ON, Canada Pediatric Dentistry make the changes. The family’s perception of eating habits Pediatric Dentistry Consultant Jeffrey A. Dean, DDS Vice-President for Clinical Quality/ and lifestyles is another obstacle. Do they even think that it is Diplomate, American Board of Development Pediatric Dentistry Kool Smiles an issue? A lot of our patients that come in, since they are Diplomate, American Board of Indiana University Orthodontics Atlanta, GA not technically seen as sick yet, tend to overlook the prob - Ralph E. McDonald Professor of lem. Changes are not being made as a family. As I was men - Pediatric Dentistry and Guest: Professor of Orthodontics Amanda E. Garant, BS, MS tioning before, the entire family needs to be on board for Indiana University School of Coordinator, Riley Hospital Dentistry for Children these changes to be made. Another obstacle is working fami - Indianapolis, IN POWER program Indianapolis, IN lies with busy schedules. Do the parents have time to help Dennis J. McTigue, DDS, MS Diplomate, American Board of assist the child in making these changes? And split homes is Pediatric Dentistry Professor, Department of Pediatric another concern and issue that we see — the family or the Dentistry The Ohio State University College parents might be on board, but if they spend a lot of time with of Dentistry the grandparents, it might alter their new healthy ways of life. Columbus, OH And then the last barrier is the “health halo”. This is a con - Method of Participation: To receive credit for this activity, answer the practice quiz questions, read the content, and complete the online post activity quiz at www.practicalreviews.com. Log in using your email cept that refers to people seeing a food as healthy, so they address and password, click on “Take a Quiz” and enter the e-quiz code located on the front page or above the quiz questions. To obtain documentation of participation, you are required to submit an activity evaluation . feel they can eat more of it. A common example of this is or - Hardware/Software Requirements: The web-based activity requires a version 4.x web browser or newer ganic snacks, such as organic cookies. Because they are or - and is best experienced using a current generation browser such as Internet Explorer 6.0 or newer or Firefox 1.5 or newer. The presentation component is designed for 1024X768 screen resolution or better. Cookies ganic cookies, they think they can eat more, so they just tend must be enabled to take the self-assessment, complete the evaluation, and print the CME certificate. to eat more calories. Media: Internet access to pdf. Intended Audience: Pediatric Dentists and others interested in pediatric dentistry . Educational Objectives: This program is designed to provide the participant with a bi-monthly overview of the most current, clinically useful information available in contemporary journals. Advances in the diagnosis If possible, after you obtain the height and weight, calculate and treatment of primary and comprehensive preventive and therapeutic oral health care for infants and chil - dren through adolescence, including those with special health care needs will be covered. It is designed to the BMI and plot it on the two- to 20-year-old growth chart expand upon, reinforce and give additional perspective to the participant’s own selection of journal readings . from the Centers for Disease Control. If this is not possible, Completed continuing education hours help meet the CDE requirements for many state dental boards, state and local associations and hospitals and clinics. Since criteria vary, participants are advised to then maybe encourage the family to discuss this with their check directly with the appropriate board or organization for applicability of 2.0 hours in Category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit primary care physician at their next visit. But during your that he/she actually spent in the activity. exam, there are lots of things that you can discuss with the Controversies, advantages and disadvantages of diagnosis and treatment plans are emphasized . After completing each month’s activity, the participant is expected to have a working familiarity with the most family on healthy ways of life. Try implementing some of clinically important information and perspectives presented . these into your dental visit. It is very easy for you to mention Special Prerequisites for Participants: There are no prerequisites for participants. something such as, “I’m looking forward to my lunch today. Accreditation: Practical Reviews in Pediatric Dentistry is endorsed by the American Academy of Pediatric Dentistry . My plate is going to have so many colors on it! What’s your Designation: Earn a Maximum of 2 CE credits per issue from the American Academy of Pediatric Dentistry . favorite color of food?” And another example could be, “I was Estimated Time to Complete Each Issue: 2 hours. Minimum Performance Level: Questions should be answered based on the information presented in the at the store the other day and I picked up a new fruit. I tried a issue within 24 months of publication date, and 70% of questions must be answered correctly to pass the quiz and receive credit for the issue . passion fruit. Have you ever had that before?” Disclaimer: The opinions and recommendations expressed by the faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Oakstone Medical Publishing name implies review of educational format design and approach. Please re - When discussing the BMI with patients, it is important to ex - view the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients. plain what BMI is and why it is used. We use BMI as a com - Full Disclosure Policy: Disclosures of relevant financial relationships have been assessed for conflicts of interest with all faculty, authors, editors, and any individuals who are in a position to control the content mon measure for understanding where the child falls within of this CDE activity. Any identified relevant conflicts of interest were resolved for fair balance and scien - the normal healthy range for age and gender. Children that tific objectivity of studies utilized in this activity. Oakstone Medical Publishing’s planners, reviewers, and editorial staff disclose no relevant commercial interests . fall above the 85th percentile are at risk for obesity, and chil - Dr S. Thikkurissy reports: Advisory Role: AAPD; Board Membership: ABPD; Employment: OSU . The follow - ing faculty report no relevant financial interests: Amanda E. Garant and Drs Joel Berg, Michael J. Casas, Jef - dren that fall above the 95th percentile are classified as frey A. Dean, Dennis J. McTigue, Arthur J. Nowak, Rebecca L. Slayton, Erwin G. Turner, and Paul O. Walker. obese. Use these growth charts as a guide, and never com - Oakstone Publishing, LLC • 100 Corporate Parkway • Suite 600 • Birmingham, AL 35242 • (800) 633-4743 pare a child to another child. Just explain that the 50th per - Copyright 2012 Oakstone Publishing, LLC. Copyright strictly reserved. The content of this newsletter may not be reproduced in whole or in part without written permission of Oakstone Publishing, LLC. centile is what we have found to be the healthiest range, and Note: Content largely consists of abstracts from the medical literature and is not intended to be an exhaustive dissertation on the articles discussed.

2 we would love to have all children close to that range to de - about how many cavities children have but less often de - crease the risk of health-related concerns. scribe the effect of those caries lesions on the child’s life — the true outcomes that have real impact on the children and There are also some easy things to tell your families before their families. A recent study assessed the impact of dental they leave your appointment or check-up. Tell them to drink caries prevalence and the effects of untreated cavitated only water and low-fat milk, increase their fruits and vegeta - caries lesions that have extended into the dentin on the bles by trying to make half their plate fruits and vegetables, quality of life of six- and seven-year-old children. make at least half of their grain whole grains, and then the main thing for that is to make sure the first word in the ingre - Nearly 600 school children were evaluated using the ICDAS dients is whole . Increase activity to 60 minutes a day, mak - index to identify the number and extent of their caries lesions. ing sure their heart rate is up and their heart is pumping. In addition, a method to determine the consequences of the Decrease screen time — including computer, TV, texting, caries lesions was documented via the so-called pufa index iPod and video games — to two hours or less a day. Also, that has been previously described. If the child had a history tell them to brush their teeth regularly so the taste of food is of toothache or extraction, that fact was noted. A modification better. A clean mouth always allows you to get the true taste of a previously used index called Childhood Oral Health Im - of new foods. And plan ahead; when they are on the go, pact Scale was employed to document the child’s oral health they will already have a plan set, and they know what their quality of life. A multiple logistic regression analysis was used next meal will be or what their next snack might be. to explore potential relationships between the existence of dentin-affected caries lesions, the effects of those lesions in These patients tend to see you more than any other doctor, the form of a pufa score, history of extraction or toothaches so remember to lead by example. Provide healthy snacks or and the oral health-related quality of life score. Three-fourths recipes in your waiting area. And we have a POWER monthly of children had cavitated caries lesions which extended into newsletter that we would gladly provide to you if you would dentin. One-fourth of children — one-third of those with dentin like to give that out in your waiting area. Provide resources for caries lesions — had effects of those lesions that manifested other activities that they could be involved with within your beyond the teeth. One-fifth of the children reported tooth- area. Provide empathy, because change is definitely not that aches, and nearly 10% had extractions performed. Merely easy. Never assume that the family has already tried to make having had a dentin located caries lesion doubled the odds of these changes. Assist the person in developing reasons for having a lower quality of life. Having had effects of those le - change, and assist the person in weighing the benefits of sions beyond the teeth and/or having a toothache increased changing versus not changing. the risk of lowering the child’s quality of life by six times.

We all need to work together to make the new generation This study provides exactly the kind of data we need to ex - the healthy generation. With the help of all healthcare pro - press the real consequence of having “cavities”. Too often, fessionals, we can make this happen. Let us fill in the gaps. society associates having a cavity as a nuisance and thereby Look for weight management programs throughout your writes it off as an inconsequential disease. We spend $65 bil - community by contacting your local hospitals. And if you lion each year in the United States alone treating the effects have any questions or would like more information, please of dental caries, yet we have little data to support the suffer - feel free to contact me by email at [email protected] or ing of children (and adults) as a result of caries. We need you can call our office at 317-948-9088. many more studies such as this. Although there is much an - ecdote we believe regarding the effects of caries, hard data will bring improved funding and awareness.

Critical Discussion and Commentary Toothaches & Cavities Both Affect Long-Term Healing Outcomes in Regen - Children’s Well-Being erative Endodontics Are Still a Mystery Different cell types can occupy the pulp canal More data support that there is significant space following trauma and can affect the morbidity associated with caries in children long-term prognosis for success

By Joel Berg, DDS By Dennis J. McTigue, DDS, MS Based on: Leal SC, Bronkhorst EM, et al. Untreated Cavi - Based on: Andreasen JO, Bakland LK. Pulp Regeneration tated Dentine Lesions: Impact on Children’s Quality of Life. After Non-Infected and Infected Necrosis, What Type of Tis - Caries Res 2012; 46 (March): 102–106. sue Do We Want? A Review. Dent Traumatol 2012; 28 (Feb - ruary): 13–18. lthough we go to great lengths to explain the signifi - cant impact of having a cavity to parents, caregivers, uch attention has been given to regenerative en - legislators and research funding entities alike, there dodontic techniques which reportedly "revascularize" eAxists a paucity in available good data documenting the necrotic pulp tissue in immature teeth, leading to morbidity of dental caries in children. We spend time talking Mphysiologic root maturation, and we have discussed a

3 number of related papers in Critiques over the past couple of years. We know that traditional apexification techniques using Do Not Rinse After Tooth Brushing

calcium hydroxide (CaOH 2) have lost favor because the pro - cedure is lengthy, taking a year or longer, and the CaOH 2 Rinsing with water reduces the benefit of weakens root dentin, leading to cervical root fractures. brushing with fluoride toothpaste; “spit But many questions remain about what is really happening in don’t rinse” should be promoted these regendo techniques. Are we truly replacing the pulp By Arthur J. Nowak, DMD with tissue identical in structure and function, or are we actu - Based on: Pitts N, Duckworth RM, et al. Post-Brushing Rins - ally “repairing” the pulp with other tissue — and if that is the ing for the Control of Dental Caries: Exploration of the Avail - case, how will that replacement tissue behave over the long able Evidence to Establish What Advice We Should Give Our term? Authors of a recent study have broached these ques - Patients. Br Dent J 2012; 212 (April 13): 315 –320. tions in an interesting paper.

Their review assesses present knowledge about the nature e know brushing two times a day with a fluoride of tissue growing into canal spaces in regenerative endodon - containing dentifrice has shown a preventive factor tic techniques and how that tissue will function in the long of about 25% in children. We also know the amount oWf dentifrice should be regulated dependent on the child's term. The authors note the optimal outcome of regendo tech - niques would be to grow pulp tissue in the canal that could age, that brushing should commence as soon as the first deposit new hard tissue on canal walls and that could re - tooth erupts and should be supervised by an adult, and that spond to noxious stimuli by producing tertiary dentin. That two brushings per day are recommended with the final brush - outcome would truly define "regeneration" of the structure ing before bedtime. What has not been well-promoted is and function of pulp tissue. Published data thus far, however, post-brushing rinsing. What I have observed is brushing for a have not provided precise information confirming true regen - period of time, spitting out excess toothpaste and then rins - eration of pulp tissue. ing with water. Does it not seem counterintuitive to spend the time brushing and making sure that the fluoride paste is Based on current literature, the authors describe four healing brushed on to every surface and crevice and then proceed - scenarios according to tissues growing into root canals. The ing to rinse the mouth and remove much of the fluoride from first is revascularization of the pulp with accelerated dentin on and around the teeth? Why do we tell our patients not to formation leading to pulp canal obliteration (PCO). This usu - drink any water for an hour after topical applications, but say ally occurs after luxation injuries with displacement in imma - nothing about rinsing after brushing? What evidence do we ture teeth and has a relatively good long-term prognosis. The have not to rinse after brushing? second healing scenario is ingrowth of cementum and dentin. This has occurred in the coronal segment of root-fractured Authors of a recent study gathered and examined the litera - teeth, and the long-term prognosis is not known. Third, in - ture with the aim to produce a consensus on post-brushing growth of cementum, dentin and bone seems to occur when rinsing. The topic of fluoride retention after use of a fluori - Hertwig's epithelial root sheath is damaged or when an dated toothpaste was initially studied and reported by Duck - avulsed tooth is improperly stored before replantation. Inter - worth in 1991. He showed a rapid drop in fluoride estingly, the presence of bone inside the canal has been as - concentration over the first 30 minutes, then a slower de - sociated with internal ankylosis-related resorption and cline. Rinsing after brushing affects retention of the fluoride infraposition of the crown. Finally, ingrowth of bone and bone and subsequent clinical efficacy. Four behaviors have been marrow has been observed, and the prognosis for long-term noted in post-brushing rinsing in real-life settings — rinsing success in these cases is not good. with water from a cup or glass, sipping water directly from the tap, sipping from a cupped hand and conveying water to the It is obvious we still have many questions about the healing mouth with a brush. and long-term prognosis of teeth undergoing regendo tech - niques. From the four healing scenarios described by the au - Observations and reports state rinsing is the norm and with thors, it is clear that different cell populations can occupy the water the most popular. Studies report caries increments are pulp spaces after trauma or transplantation and they can af - higher in subjects that rinse compared with those that do not fect the long-term prognosis for success. Still, the advan - rinse. An alternative method suggested is to brush with a fluo - tages of physiologically repairing necrotic pulps in immature ride containing paste for two minutes without expectorating, teeth seem to outweigh the disadvantages of traditional then sip water to make a slurry, then actively swish for one minute, then expectorate with no rinsing, eating or drinking for apexification with CaOH 2, and much more research in this exciting field is needed. two hours. This would be an excellent method to recommend for the final brushing before bedtime. The AAPD guidelines on brushing with a fluoridated toothpaste states, "to maximize the beneficial effect of fluoride in toothpaste, rinsing should be kept to a minimum or eliminated altogether."

The group did not arrive at a consensus because of the lack of high-quality evidence (randomized controlled studies) on the topic but stated their statement should be considered as an expert opinion with strength of evidence from at least one meta-analysis. Some of the consensus opinions are rinsing with water reduces the benefit of brushing with fluoride

4 toothpaste; “spit don’t rinse” should be promoted; in children, quite sobering. The study did have a number of limitations — brushing/rinsing should be supervised until confident that the the investigators only reviewed medications available to and child will not drink the rinse; and brushing should be done used by anesthesiologists, and other institutions or facilities two times a day. may have other drugs available for use by anesthesiologists. In addition, the investigation did not review drug labeling in other countries, only those covered by the FDA.

While this article might seem to be critical of physicians, I am aware that many dentists involved with the oral health of chil - dren have never reviewed the manufacturer’s insert which Are You Using Medications for details the FDA indications, age-dosing and toxicity. Children Without FDA Approval?

Off-label is defined as the unauthorized use of a drug for a purpose other than approved by the U.S. Food and Drug Administration Forget the Fluoride Rinsing & Get Back

By Paul O. Walker, DDS, MS Based on: Smith MC, Williamson J, et al. Off-Label Use of to the ABCs Medications in Children Undergoing Sedation and Anesthe - sia. Anesth Analg 2012; March 26: epub ahead of print. School-based fluoride programs work best in high-risk populations he phrase off-label use of medications can be confus - By Arthur J. Nowak, DMD ing. It is defined as, “the unauthorized use of a drug for Based on: Divaris K, Rozier RG, King RS. Effectiveness of a a purpose other than approved by the United States School Based Fluoride Mouthrinse Program. J Dent Res TFood and Drug Administration [FDA].” In dentistry, fluoride 2012; 91 (March): 282–287. varnishes and chlorhexidine are often used in an “off-label” manner. It appears the use of off-label medications is a com - mon practice in pediatric medicine as well. The FDA estab - chool-based fluoride rinse programs were popular be - lished indications, dosing and age limitations for medications fore communities were adding fluoride to their water based upon evidence from clinical trials, often supported by systems and in rural communities without community pharmaceutical companies. However, about 80% of medica - Swater systems. In a recent report from the Centers for Dis - tions licensed for use in the United States have not been ap - ease Control, 73.9% of United States citizens (204+ million proved for use in children. It is for these reasons that a recent people) on community water systems are drinking fluoridated article grabbed my attention. water, but 72 million citizens remain without fluoride from community water systems not adjusted. Daily fluoride supple - The study involved a review of drugs administered by anes - ments have lost their popularity because of the need for pre - thesiologists during anesthesia or for purposes of pain scriptions and compliance issues. A 2003 meta-analysis management. There were 106 medications regularly adminis - reported a 26% reduction in caries in permanent teeth and tered. Using the Thomson Micromedex ® online database, the children enrolled in school-based fluoride rinse programs. FDA labeling and indications for patients under 18 years of age were determined. The drugs were then categorized in Schools have been the venue for many health and social pro - three areas — not FDA labeled for use in any pediatric age grams because of a captive audience from K–12 for nine to group, FDA labeled for use in all pediatric age groups, and 10 months of the year. Teachers object to the amount of time FDA labeled for use in limited age groups. The drugs that did required and the mess to clean up after rinsing. Costs vary not have FDA approval for use in pediatric patients were then depending on paid staff or volunteers to administer the pro - further examined to determine the strength of the evidence gram from $0.52 to $2.54 per child per year. Some reports and the strength of the recommendation for each indication. question the cost benefits of the program. Presently, 35 states have active school fluoride rinse programs, mostly in The authors also looked at the rate of off-label drug use in non-fluoridated and high-risk communities. So, what new evi - patients under 18 years of age in operating rooms from July dence is available on the use and effectiveness of school- 1, 2010 to August 31, 2011. The authors reported that, of the based fluoride mouth-rinse programs? 106 drugs identified as being available to anesthesiologists, 40 (38%) were FDA labeled for patients of all ages, 36 (24%) The aim of a recent study was to estimate the caries preven - had no FDA indications for patients under 18 years of age tive effects of school-based programs in North Carolina and and 30 (28%) were FDA labeled with age-specific limits. In secondly whether the effectiveness varied by school level all, 73% of the drugs were used in an off-label manner. Of caries risk indicators. these, many of the most commonly used drugs were pedi - atric patients; neostigmine, hydromorphone and dopamine Researchers performed a secondary analysis 2003–2004 were FDA labeled not for use in any pediatric age group. North Carolina Oral Health Survey that used clinical and par - ent information for children from first to fifth grades. Years of The authors concluded that many drugs used for pediatric participation in rinse programs were calculated; caries in pri - patients during anesthesia lacked FDA labeling for pediatric mary teeth was recorded upon examination after cleaning with use. Needless to say, this article, although informative, was a toothbrush, drying with compressed air and visualizing the

5 teeth aided by a light source. Community water fluoride sta - though only 9% of the sample students had participated for tus was determined, and the number of children in school four years of the rinse program. The authors felt that un - lunch programs was included in the analysis as risk factors. treated decay in kindergarten children was a superior Untreated primary teeth cavities in kindergarten children marker to identifying risk of children as compared to enroll - were used in the analysis to further determine risk status. ment in free lunch programs.

The results showed the mean caries raLtOeGsO in grades one Even though the findings overall lack significance, the au - through five was 4.1 surfaces on primary teeth and 0.7 sur - thors feel, if compliance over the length of the program is im - ICON faces on permanent teeth. Fluoride mouth rinse participation proved, children identified as high risk would benefit from showed minor reductions in caries prevalence but was more school fluoride rinse programs. pronounced in high-risk schools. The overall effectiveness of weekly rinse programs was weak and not significant, but in Maybe rinsing is not the best way to go. How about fluoride the high-risk groups the long-term effects were present even varnish applications instead? More research is needed.

1 - Color 1 - Color PMS 646 PMS 646 Literature Reviews reviews What Kinds of Oral Appliances Best Manage Acute & Chronic Illnesses

Sleep Apnea? 4 - Color Process 4 - Color Process C = 71 Objective: To discuss oral appliance funCc =t i7o1 nal orthodontic devices such as : Take Home Pearl M = 29 (OA) therapy for OSA. rapMi d= 2m9 axillary expanders have been Y = 0 Y = 0 In children, rapid maxillary shown to be effective management K = 32 Design: Review article. K = 32 expansion may be an effective tools for OSA. therapy for obstructive sleep Discussion: There is a wide range Conclusions: Consistent follow-up apnea. (>100 reported) of different OA de - and management are needed to in - signs. Most of these involve reposi - crease clinical success rates in OA tioning the tongue or mandible to allow Background: Obstructive sleep therapy for OSA. apnea (OSA) is defined by repeated for less airway obstruction. Interest - apneic episodes due to upper airw1a - y Color Gradienngt ly, when dentists were surveyed Reviewer’s Comments: This is a re - obstruction. There is also an associ - Black previously, 58% could not identify ally thorough review of the use of oral ated reduction in oxygen saturation common symptomatology associated appliances. I was shocked that previ - levels, as well as breathing distur - with OSA. OAs have been demon - ous literature indicated 50% to 60% of strated to have clinical efficacy rates dentists were not aware of signs and bances and snoring due to redundant LOGO tissue impeding air flow. The current similar to the CPAP but are often pre - symptoms of OSA. I am sure this rate ferred due to being less invasive. is higher in pediatrics, because pedi - gold standard for assessment is ICON laboratory-based polysomnography, Titratable OAs (those that can be ad - atric sleep disturbances are so poorly which can be expensive and is very justed with symptoms) were found to understood. technique-sensitive in terms of inter - be superior to fixed OAs. Short-term S. Thikkurissy, DDS, MS pretation. Other common therapies for side effects of OAs include hypersali - Reviewer: 1 - Color Solid 1A - rCtoiclolre S oRlideviewed: Chen H, Lowe AA. OSA include weight loss, alcohol Black vation, mucosal dryness, myofascial UpdBlactek s in Oral Appliance Therapy for avoidance, changes in sleeping habits stiffness, and temporomandibular joint Snoring and Obstructive Sleep Apnea. 1 - Color S1le -e Cpol oBr reath 2012; May 6: epub ahead and positions, oral appliances, and PMS 646 discomfort, but these are all largely PMS 646 of print. continuous positive airway pressure transient. Long-term compliance with (CPAP). Finally, there is a range of OAs has been demonstrated to be surgical procedures that have been around 45%. In children, OAs have used to address OSA as well. poorer compliance rates, and

Drooling & Aspiration — A Deadly Combination Acute & Chronic Illnesses 1 - Color Solid Reversed 1 - Color Solid Reversed White White 4 - Color Process 4 - Color Process C = 71 aspiration of saliva, which can be aspi - weCr e= 7u1 sed to assess passive saliva Take Home Pearl: M = 29 rated during dysfunctional swallowing. asMp i=ra 2t9 ion. In patients with CP, Parkin - Posterior drooling is defined as Y = 0 Whereas many patients demonstrate sonY =d i0 sease, and amyotrophic lateral K = 32 K = 32 escape of saliva through the anterior drooling that escapes the oral sclerosis, botulinum neurotoxin A faucial pillars. cavity, some also demonstrate poste - (BOT) has been used to treat chronic rior drooling, which can build up in the uncontrolled drooling. upper and lower airways. Posterior Background: Patients with neurologic Objective: To assess saliva aspiration drooling is defined as the escape of disease such as cerebral palsy (CP) in patients following BOT administra - saliva through the faucial pillars. In the can be at greater risk for pulmonary tion using 2 case studies. complications following chronic 1 - Color Gradlieantte 1980s, radionuclide salivagrams Black 6

1 - Color Solid 1 - Color Solid Black Black

1 - Color Solid Reversed 1 - Color Solid Reversed White White LOGO Case Discussion: In both cases dis - demonstrated, and in 1 case a reduc - paper. Another key feature here is re - cussed, patients initially presented tion in the amount of saliva build-up in ducItCiOoNn in drooling may also affect pro - with excessive drooling that was signif - the lower esophagus was demon - gression of demineralized areas into icantly affecting quality of life. Saliva - strated as well. In both cases, reduc - full-blown cavitated carious lesions, and grams were used to establish tion of anterior and posterior drooling dentists need to be aware of these ther - pulmonary aspiration of saliva, and was associated with improved sleep apies and their impact on oral health. subsequently, injection of BOT was habits in these patients. carried out bilaterally into the parotid 1 - Color R1e v- Cieolwor er: S. Thikkurissy, DDS, MS Reviewer’s Comments: BOT is an in - Park HW, Lee WY, et and submandibular glands. The BOT PMS 646 APrMticS l6e46 Reviewed: creasingly common treatment modality al. Salivagram After Gland Injection of was diluted with 0.9% saline solution for CP patients. I really was not aware Botulinum Neurotoxin A in Patients With to 100 units/2 mL. In both cases, re - Cerebral Infarction and Cerebral Palsy. of the concept of anterior drooling ver - duction in saliva aspiration was PM&R 2012; 4 (April): 312 –216. sus posterior drooling until I read this

No Sleep for Child Means No Sleep for Mom Acute & Chronic Illnesses

4 - Color Process 4 - Color Process C = 71 Participants/Methods: Mothers of CoCn =c 7l1usions: Sleep disturbances are Take Home Pearl: M = 29 children with CP were asked to com - moMr e= 2p9 revalent in the CP population Forty percent of mothers of kids Y = 0 plete a questionnaire that included de - andY =h a0 ve profound impact on maternal K = 32 K = 32 with cerebral palsy were classi - mographics, sleep-quality indices, functioning. fied as having poor sleep quality depression components, and child Reviewer’s Comments: This is a real associated with their child’s sleep habits. Other generalized data eye-opening study that demonstrates a sleep disturbances. included history of prematurity, comor - childhood chronic illness really is a fam - bid epilepsy, visual impairments, and ily illness. Studies have demonstrated reflux. Cognitive impairment was also Background: Cerebral palsy (CP), or repeatedly that parents of children with noted for children. static encephalopathy, has been 1 - Color Gradient special health needs have poorer Black demonstrated to affect up to 3% of live Results: Data were collected from 40 health themselves and are at astro - births in the developed world. Because children-parent dyads and 102 controls. nomically higher risks for divorce, finan - the etiology of CP rests in brain injury, Children were between the ages of 4 cial problems, and psychopathology. I these children have demonstrated sig - and 12 years. Within the cohort, 35% of always try to remember this when nificantly higher rates of sleep children had quadriplegic CP. The CP these families come late to appoint - disturbances/parasomnias. General in - children had significantly worse sleep ments, as they are tackling a world of tellectual disability has also been asso - disturbances, LiOnGcOluding more frequent issues beyond the walls of my practice. ciated with higher rates of sleep night-waking and sleep anxiety. Many ICON disturbances, as have visual impair - of the CP children were also identified Reviewer: S. Thikkurissy, DDS, MS Article Reviewed: Wayte S, McCaughey ments, which may both be features o1 f - Color Solwid ith sleep-disordered breathing. Distur - 1E -, C eotlo ar Sl.o Slid leep Problems in Children With cerebral palsy. Sleep disturbances Black bances in child sleep were highly asso - CerBelabcrk al Palsy and Their Relationship have been associated with pediatric be - ciated with disturbance in maternal With Maternal Sleep and Depression. havioral aberrances. The sleep distur - sleep, which was also associated with Acta Paediatr 2012; 101 (June): 618 –623. bances of a child have also been higher rates of maternal depressive shown to impact the sleep patterns and 1 - Color 1 - Color symptoms. InP MthS e64 C6 P group, 40% of PMS 646 mental and overall health of the family. mothers were classified as having poor Objective: To assess associations be - sleep quality. Maternal sleep quality ac - tween child sleep, maternal sleep, and counted for 50% of variance in mater - maternal mood within a cohort with CP. nal depression scores.

1 - Color Solid Reversed 1 - Color Solid Reversed White White Understanding What Is Going on in Saliva May Cariology

Reveal More Than We Think 4 - Color Process 4 - Color Process saliva and its Cfa =c 7t1ors. Seldom do we whole saliva of the chiCld =, 7 a1 nd the pH of Take Home Pearl: describe the eMf f=e 2c9 ts of saliva on caries the child’s plaque biofMilm = 2 a9 fter a 20% Variation of salivary carbonic prevention andY =o 0n caries rate reduc - sucrose challenge rinsYe =. 0 K = 32 K = 32 anhydrase isoenzyme VI activity tion. Similarly, we have very little data Participants/Methods: 30 children and child’s age are associated looking at the constituent components aged between 4 and 6.5 years were with dental caries in preschool of saliva and their effects on caries in divided into a caries-free group and a children. primary teeth specifically. group that manifested caries lesions. Objective: To look at a specific isoen - Each child was examined, and all of Background: We know that dental zyme in saliva called carbonic anhy - the mentioned whole saliva factors as caries in children as well as in adults is drase isoe1n - zCoylmor eGr aVdIie (nCt AVI) in well as the CAVI level were calculated Black the result of demineralization of preschool children with caries lesions both before and after the 20% sucrose enamel and dentin caused by acid and to examine the relationship be - rinse. Various correlation analyses production of plaque biofilms. This tween caries lesion presence and sali - were then performed. caries activity is mediated via the vary CAVI activity, the flow rate of the

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1 - Color Solid Reversed 1 - Color Solid Reversed White White Results: Prior to the sucrose rinse, Reviewer’s Comments: CAVI activity in saliva and their effect on the primary the children who had caries lesions in other studies that were performed dentition. It would be interesting to take had a higher CAVI level. After the su - with differing methodologies has shown a look at very young children, including crose rinse, there was no difference that having caries lesions reduces the those who manifest early childhood between the cavity present and cavity- LOCGAO VI level, contrary to the present caries versus those who do not, and to free children as far as their CAVI lev - study. CAVI activity is associated with a measure their respective salivary CAVI ICON els. The pH dropped in both groups protective effect on enamel. CAVI aids levels, along with other salivary factors after the sucrose rinse, and the whole in the deposition of minerals and in the that might be modulated or might be saliva flow rate increased in both protection against further demineraliza - mitigated by such salivary constituent groups after the sucrose rinse. Caries tion. In this respect, the results re - elements. activity in older children was observed ported in the present study indicate to be higher than in younger children. that saliva’s reaction to caries lesions Reviewer: Joel Berg, DDS 1 - Color 1 - Color Frasseto F, Parisotto is to provide enhanced protective fac - Article Reviewed: Conclusions: Variation of salivary PMS 646 TM, etP MalS. 6R46elationship Among Salivary tors. The response to a challenge CAVI activity and child’s age are asso - Carbonic Anhydrase VI Activity and Flow brought on by a caries lesion is to im - Rate, Biofilm pH and Caries in Primary ciated with dental caries in preschool mediately begin to repair that lesion. Dentition. Caries Res 2012; 46 (April 13): children. 194 –200. We know little about various elements

Child Abuse Is Not Associated With Later Obesity Child Abuse & Neglect

4 - Color Process 4 - Color Process C L= o71 s Angeles County Department of ConcluCs =i o71 ns: Maltreatment was not Take Home Pearl: M C= 2h9 ildren and Family Services. BMI associaMt e= d29 with higher BMIs in children. There is no significant associa - Yw = a0 s measured, with weight being Y = 0 K = 32 ReviewK e=r 3’2 s Comments: As I read tion between maltreatment and measured 3 times to ensure accuracy. this, my thought is that we really a higher body mass index. Three groups were created: normal needed to understand whether these weight, overweight/obese (>85% BMI), maltreated children had any underly - and obese. Background: Child maltreatment has ing psychological issues, because that been shown to have long-ranging im - Results: Data were collected from might be more prevalent as a barrier plications for the child’s overall well- 303 maltreated children and 151 con - to higher BMI. These children may being and development. Chronic LOG1O - Colotr rGoralsd.ie Tnt he maltreated group was bro - have issues with diet after having Black health problems, behavioral distur - ken down into neglect (77%), been maltreated. It is a sobering arti - bances, and educational setbacks are emotional abuse (51%), physical cIlCeO nN onetheless and demonstrates that all common features of the maltreated abuse (51%), and sexual abuse we really have limited long-term child. No literature has reported on (21%). Children may have experi - knowledge on what happens physio - whether overweight status may be af - enced >1 form of maltreatment. A logically when a child is maltreated. fected by a history of maltreatment. significantly higher number of the maltreated group had BMIs >85%; Reviewer: S. Thikkurissy, DDS, MS Objective: To assess the prevalence Schneiderman JU, 1 - Color however, there was no significant as - 1A - Crtoilcorle Reviewed: of body mass index (BMI) in a popuPlMa S- 646 PMSe 6n4n6 en FE, et al. Overweight and Obe - sociation between maltreatment and a tion of maltreated youth and controls. sity Among Maltreated Young Adoles - 1 - Cohloirg Sholeid r BMI. Females who were physi - cents1 .- Cohloirld S oAlidbuse Negl 2012; May 7: Participants/Methods: Subjects were Blcaack lly abused and/or sexually abused epub ahBelaackd of print. studied from the files of the had lower BMIs.

Behavior Guidance in Autistic Patients Developmental Disabilities

4 - Color Process 4 - Color Process C = 71 consequence-based imitation. Much of RCe =v 7i1 ewer’s Comments: Yes, this is a Take Home Pearl: M = 29 autistic children’s learning methods in - “Mto =u 2c9 hy-feely” paper for sure, but it has The lack of social gaze in Y = 0 volve one-on-one interaction with an soY m= 0 e real valid points, and it rein - K = 32 K = 32 autism can lead to an inability 1 - Color Soaldidu Rletv ienrs ead very structured format to map fo1r -c Ceoslo ro Suolrid u Rseeve rosef d tell-show-do, as well White White to learn through observation. out the concept of consequences. Po - as management of patients with tential methods that would benefit autism. Short, directed statements, not autistic patients include short state - overloading the patients, are critical for Discussion: Learning by observing is ments with focused objectives rather compliance. The lack of social gaze a significant manner by which children than “story telling.” A major challenge is means that autistic children often miss interact with their environment. Chil - instructing autistic children to imitate out on the opportunity to learn about dren learn about consequences 1 - Color Gradient Black without being told or having verbal consequence from watching others through observation. It has been cues. This is due to the fact that many succeed/fail. Pediatric dentists need to demonstrated that children with autism autistic children have poor social inter - make sure to frame the context of demonstrate a sometimes profound action/visual gaze, so they may not ob - treatment for the child who has no deficiency in learning through observa - serve peer actions and rather may wait concept of what is happening other tion. Children with autism may act sim - for a verbal cue to exercise imitation. than pain or discomfort. I found this ply out of repetition or non–

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article fascinating in its recommended Reviewer: S. Thikkurissy, DDS, MS With Autism. Behav Modif 2012; May 7: strategies, which mirror the AAPD be - Article Reviewed: Taylor BA, DeQuinzio epub ahead of print. havior guidance guidelines. JA. Observational Learning and Children

What Is That Smell? Hospital & Operating Room

4 - Color Process 4 - Color Process C = 71 Participants: The study included InC =a 7d1 dition, the number of antiemetic Take Home Pearl: M = 29 screening >1,100 patients, of which mMe =d 2i9cations requested by the patients Aromatherapy appears to be an Y = 0 303 were included. The eligibility crite - wYa =s 0 also significantly less with ginger K = 32 K = 32 effective intervention for postop - ria included adult patients able to pro - oil ( P <0.002) and the blend of essen - erative nausea. vide informed consent with no history tial oils ( P <0.001). of coagulation problems or allergy to Conclusions: The hypotheses that any of the aromatherapy agents. Background: Postoperative nausea is aromatherapy would be effective as a common following the use of anesthe - Methods: The subjects rated the de - treatment for postoperative nausea was sia and surgery. While antiemetic med - gree of nausea using a verbal descrip - supported, and the authors believe that ications can be utilized, they do n1 o- Ct oLlOorG GO radientit ve scale with a range from 1 to 3. further research evaluating the effec - Black have reliably predictive effects. Patients with a nausea scale rating of tiveness of aromatherapy is warranted. 1 to 3 received a gauze pad saturated ICON Objective: To hypothesize that, when Reviewer’s Comments: Unfortu - with a randomly selected aromather - compared to inhaling a non-aromatic nately, this study was conducted only apy agent and were instructed to in - placebo, postoperative nausea would on adults, but a similar study involving hale 3 times. The nausea scale was be significantly reduced with the use of only children would be a valuable ad - then repeated in 5 minutes. 3 different aromas — essential oil of dition to the scientific literature. ginger; a blend of essential oils of gin - Results: The change in nausea level 1 - Color 1 - Color Paul O. Walker, DDS, MS ger, spearmint, peppermint, and carP-MS 646 scoring was significant for the blend of PRMSe 6v4i6ewer: Article Reviewed: Hunt R, Dienemann damom; or isopropyl alcohol. essential oils of ginger, spearmint, J, et al. Aromatherapy as Treatment for 1 - Color Solid peppermint, and cardamom ( P <0.001) 1 - PColsort oSopleid rative Nausea: A Randomized Design: Randomized trial conducted Black Black Trial. Anesth Analg 2012; March 5: epub at a single ambulatory surgery site. and for ginger essential oil ( P <0.002), but not for isopropyl alcohol ( P <0.76). ahead of print.

General Anesthesia Is Safe for Healthy Children Hospital & Operating Room

4 - Color Process 4 - Color Process C = 71 was calculated as number of deaths × RCe =v 7i1 ewer’s Comments: This is a good Take Home Pearl: M = 29 10,000 per number of children anes - sMy s= t2e9 matic review that demonstrates Icreased mortality with general Y = 0 thYe = o0 verall safety of general anesthe - 1 - ColorK S =o l3id2 Revetrhsed tized. Mortality triggers were 1 - ColorK S =o 3lid2 Reversed anesthesia was associated with White categorized as surgery related, dis - siWa,h ipte articularly on healthy children, in ASA III or higher status as well ease related, and anesthesia related. developed nations for minor proce - as younger age. dures, ie, most of our early childhood Results: 20 articles were identified as caries kids. It also underscores that our meeting qualifications. Between 1961 children with special healthcare needs Background: There has been a and 2000, the mortality rate decreased demonstrated higher perioperative are at greater risk for poor outcomes, from 0.2 –2.9 to 0 –0.7. Higher mortality so early attention to oral health is criti - mortality rate in children when co1 m - C-olor Gradienrt ates (up to 3.3) were associated with pared to adults. This mortality is asso B-lack cal. The truth is that 6-month periodicity studies from developing countries. for recalls may not be adequate to stem ciated with younger age, particularly Mortality rates overall were higher in infants and neonates. the onset of dental problems in these the neonate/infant group. Increased patients, as it was the child’s underlying Objective: To assess incidence and mortality was associated with ASA III disease that was the major mortality etiology of perioperative- and or higher and the surgery being classi - trigger in most cases. anesthesia-related mortality in pedi - fied as emergency surgery. The child’s atric patients. underlying disease was the major mor - Reviewer: S. Thikkurissy, DDS, MS tality trigger in all cases. Article Reviewed: Gonzalez LP, Pigna - Design: Systematic review. ton W, et al. Anesthesia-Related Mortal - Conclusions: While the overall mor - ity in Pediatric Patients: A Systematic Methods: Literature searches wer1e - Color Solid 1 - Color Solid tality rates associated with anesthesia Review. Clinics (Sao Paulo) 2012; 67 conducted using the keywords cardiaBc lack (4B)la: c3k 81 –387. are low, the severity of the child’s dis - arrest , mortality , and anesthesia in 4 ease is still a major contributing factor major research databases. Mortality to mortality.

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Exposing Dental Students to Real-World Legal & Ethics

Scenarios May Enhance Em4 - Coplora Protchessy 4 - Color Process and moCs t= c71onsidered themselves em - that include patiCe =n 7t 1 simulations using Take Home Pearl: patheticM. =A 2ft9 er viewing the videos, en - trained actors. IMn =t h29e tertiary care hos - Although dental students see gaging iYn =d 0 iscussion about the videos, pital where I teaYc h= 0 and practice, we K = 32 K = 32 themselves as empathetic, ex - and performing a reflective writing ex - focus on family-centered care. For our posure to real patients sharing ercise, 84% of second-year students pediatric dentistry graduate students their negative dental experi - and 73% of third-year students stated and GP residents, it is common for ences was perceived as helping that these exercises enhanced their them to be overwhelmed by the com - to improve their understanding commitment to professionalism. plexity of medical conditions and the of patient concerns. Scores on the Jefferson Scale of Em - extent of the dental disease with which path1 y- Cwoleorr Ger asdtiaentit stically higher for they are confronted. Consequently, it second-Bylaecak r students than third-year might be difficult to be empathetic with Objective: To assess whether videos students. The authors speculated that families and children dealing with sig - of actual patients, not trained actors, the increasing technical demand nificant dental disease superimposed recounting their experiences of insen - placed upon upper-year students to on life-threatening medical conditions, sitivity, difficulty in accessing care, or complete clinical requirements might when most of our residents have no treatment errors associated with den - play a role in the score differences be - children of their own and cannot imag - tists will enhance dental student em - tween second- and third-year students. ine the stresses of parenting, particu - pathy for their patients. The authors have added videos to the larly under the extreme conditions we Design/Methods: The investigation curriculum of their management course regularly encounter. Videos of families had 3 components: a survey of dental at the University of Western Ontario. recounting the barriers to care that student knowledge and attitudes about 1 - Color Solid they have en1c -o Cuonlotre Sroelid may be one ConclusBliaock ns: Although dental stu - Black empathy; viewing of patient videos by way to improve young dentists’ com - dents see themselves as empathetic, dental students; and a post-video sur - passion for and understanding of the exposure to real patients sharing their vey of the students as well as comple - LOGO families they treat. That heightened negative dental experiences was per - tion of the Jefferson Scale of Empathy, empathy may enhance the care they ceived as helping to improve their un - a validated instrument for measuring provide for families and alsIoCO eN nhance derstanding of patient concerns. empathy in healthcare professionals. the residents’ personal satisfaction Nineteen videos were developed that Reviewer’s Comments: To be able to and engagement with their work lives. included 3 HIV-positive patients, 5 effectively utilize the knowledge and patients on income assistance, 4 dis - skills we teach requires that students Reviewer: Michael J. Casas, DDS, MSc, FRCD(C) abled, 6 working poor, and 1 middle- de1 -v Ceolloorp S othlide R aevberilsietdy to communicate ef - 1 - Color Solid Reversed Article Reviewed: Schwartz B, Bohay class patient who had been dismissed fectivelyW ahinte d dem1o -n Csotlorar te empathy for R. Can Patients HWehiltpe Teac1h - PCorolofr ession - PMS 646 PMS 646 from a dental practice. their patients. Various techniques have alism and Empathy to Dental Students? been employed to attempt to provide Adding Patient Videos to a Lecture Results: A pre-intervention survey re - situations where dental students can Course. J Dent Educ 2012; 76 (Febru - vealed that most students felt that they ary): 174 –184. develop empathy with their patients had a good understanding of empathy

What Is the Best Method to Correct Post-Ortho Other

White Spot Lesions? 4 - Color Process 4 - Color Process orthodontics were Cd =iv 7i1 ded into 4 groups Reviewer’s Comments: WC =h i7le1 the re - Take Home Pearl: of 20 each. GroupM 1 = b29rushed with fluor - sults of this study are not sMu =rp 2r9 ising in While treatment with fluoride is idated toothpaste; Yg =ro 0 up 2 used 20 mL that the enamel microabrasYi o=n 0 tech - K = 32 K = 32 beneficial, enamel microabra - of neutral 0.025% sodium fluoride nique was superior to the therapeutic sion remains the best way to rinse; group 3 used casein agents utilized, I was pleased to see resolve post-orthodontic dem - phosphopeptide-amorphous calcium fluoride and casein phosphopeptide- ineralized scarring. phosphate as a tooth mousse twice amorphous calcium phosphate mousse daily in addition to a fluoride tooth - both provided significant improvement Background: While several treatment paste; and group 4 underwent mi - for the scarring. This study was pro - methods are touted, there are few croabrasion tre1 a- Ctmoloer nGrta udisenint g a mixture duced from the lead author’s PhD the - comparative studies looking at the of 18% hydrochloriBcla cak cid. Photos of sis project. Its prospective, randomized, best way to manage post-orthodontic pre- and post-treatment were analyzed and controlled clinical trial nature treatment scarring. to determine the percent improvement strengthens the nature of the results. It in scarring. might have been interesting to see the Objective: To compare 4 methods to results if bleaching had been added to Results: The percent success for treat enamel scarring after orthodontic the prescribed treatment, but that will groups 1, 2, 3, and 4 was 45%, 48%, treatment. have to wait for another study. 58%, and 97%, respectively. Design: Prospective, randomized, Jeffrey A. Dean, DDS controlled clinical trial. Conclusions: Microabrasion is the Reviewer: Article Reviewed: Akin M, Basciftci FA. best method for the cosmetic treat - Can White Spot Lesions Be Treated Ef - Participants/Methods: 80 patients ment of these p1o - sCto-lorr Stholoid dontic dem - 1 - Color Solid Black fectively? Angle Orthod 201B2l;a cFk ebruary who had enamel scarring after ineralized white spot lesions. 23: epub ahead of print.

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Exposure to Dental X-Rays May Increase the Risk Other for Meningioma 4 - Color Process 4 - Color Process 1,350 controls. All Cs =u 7b1 jects were exposures used for bitewinCg = 7a1 nd other Take Home Pearl: asked to recall theM t =y p29 e of dental care radiographs today comparMe =d 2t9 o 60 Children exposed to ionizing they had in the pasYt = a 0 nd the type and years ago. Y = 0 K = 32 K = 32 radiation are at greater risk for frequency of dental radiographs they Conclusions: In this study, exposure meningioma than if exposed as were exposed to over their lifetimes. to dental x-rays in the past appears to adults. The authors also documented any oc - increase an individual’s risk for in - currence and timing of therapeutic ra - tracranial meningioma. Background: Guidelines for the use diation treatment. Statistical analysis of dental radiographs were developed was used to assess the risk of menin - Reviewer’s Comments: One addi - tional limitation is that there is a possi - in collaboration with multiple profes - giomas with ea1 c- Cho lcoor Gvradrieantt e. Logistic sional dental organizations with the regression was useBldac kto determine the bility that 2% to 4% of the control goal of minimizing exposure to ionizing odds of meningioma being associated subjects could have had an undiag - radiation and maximizing the ability to with other risk factors. nosed meningioma. This was not ad - dressed, and it is not known what diagnosis dental diseases. Results: The percentage of cases and effect this might have had. The study controls having biteLOwGiO ngs during each Objective: To assess the historical ex - should remind all of us to follow the ra - age range was similar, but cases had posure to dental radiographs and de - diographic guidelines and tIoCO liN mit ex - 2 times more bitewings over their life - termine if this exposure increases a posures to all of our patients to that times than controls. Panoramic radi - person’s risk for a common brain which is as low as reasonably achiev - ographs were more commonly made tumor known as meningioma. able and provides us with the ability to in adults than in children or adoles - 1 - Color Solid accurately diagnose dis1e -a Csoelo ri Sno laid Design: Case-control study with con - cents. There was aBnla cak lmost 5-fold in - Black timely way. trols matched for age, sex, and geo - creased risk of meningioma in children graphic location. 1 - Color 1 - Color screened with a pPaMnSo 6r4a6 mic radiograph Reviewer: Rebecca L. SlaPyMtoSn 6,4 6DDS, Participants/Methods: Subjects before the age of 10 years. Limitations PhD of the study included recall bias of ra - Article Reviewed: Claus EB, Calvo - ranged in age between 20 and 79 coressi L, et al. Dental X-Rays and Risk years, and included 1,433 cases previ - diographs made over a subject’s life - of Meningioma. Cancer 2012; April 10 : ously diagnosed with meningioma and time and changes in standard epub ahead of print.

Other Cri-du-Chat Syndrome Require1s - C oElor aSolridl Ryev erIsned tervention 1 - Color Solid Reversed White White 4 - Color Process 4 - Color Process parents. A thorougCh = c7l1 inical examina - characteristics included hyCp =e 7r1 telorism Take Home Pearl: tion was completeMd .= P29 hotographic ex - (94%), epicanthal folds (94M% = 2),9 short Early recognition and treatment amination and radiYo =g 0raphic analysis philtrum (97%), low set earYs = ( 0 78%), K = 32 K = 32 with rehabilitative and educa - were performed for compliant patients. and facial asymmetry (69%). Orally, tional interventions are essential Characteristics were categorized ac - the patients showed mandibular ret - for positive long-term outcomes cording to severity and included level rognathism (91%), high palate (55%), in patients with cri-du-chat of disability, degree of mental retarda - anterior open bite (63%), hypotonic syndrome. tion, microcephaly, hypotonia, decay perioral muscles (97%), and dental and periodontal disease, and behavior. anomalies (57%) to include oral habits Background: The cri-du-chat syn - Univariate ana1l y- Csoislo ro Gfr atdhien tresults con - with self abuse and increased drool - drome (CdCS) is a genetic disease re - sisted of a descriptBilvacek analysis of the ing. Socially, 78% of the patients were sulting from a deletion of variable size variables, and the Chi-square test was euphoric with cheerful personalities, occurring on the short arm of chromo - used to investigate the relationship be - yet 72% were hyperactive, 66% were some 5(p). tween parameters. aggressive, and all displayed continu - ous uncontrolled movements. Due to Results: Of 33 patients, 13 males Objective: To perform a retrospective these factors, 90% of these patients (40%) and 20 females (60%), the analysis of the orofacial features and required dental treatment using deep mean age was 14.65 years with a de - common oral pathology observed in sedation or general anesthesia. individuals diagnosed with CdCS. gree of disability of 73%. All the pa - tients had average birth weight, Conclusions: Familiarity with the oro - Design/Methods: The study sample gestational age1, -a Cnodlo rw Soelird e mentally facial pathology along w1 i-t hCo tlohre S odlidevel - consisted of 33 patients diagnosed handicapped with tBhlaeck majority rated opmental and behavioral dBislaock rders clinically and confirmed by means of a moderate to severe. Preliminary diag - associated with CdCS will help profes - karyotype test with CdCS between nosis was established in 94% of the sionals determine the best treatment 2008 and 2009. Information was ob - sample from a monotone weak cat-like approach and management for these tained from the patients’ medical cry during infancy. Psychomotor devel - patients’ specific oral needs. records to include birth weight, gesta - opmental delay occurred in all the pa - Reviewer’s Comments: This is a tion period, major and minor malfor - tients, who exhibited altered suction good retrospective study with a very mations, and other medical problems. (72%), generalized muscle hypotonia good sample size for this particular Oral health information was gathered (88%), dysphagia (52%), and gastroe - syndrome. For the most part, the from questionnaires completed by the sophageal reflux (66%). Other general 1 - Color Solid Reversed 1 - Color Solid Reversed White White 11 LOGO

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findings were consistent with previous Also, much of the 1e -a Crollyor dental-related Reviewer: Erwin G. Turner1, -D CMoloD r similar studies. A limitation was that information was bPaMsSe 6d4 6 on parental Article Reviewed: RodríguPeMzS- 6C46aballero not all examinations and question - recollection, and there was no discus - A, Torres-Lagares D, et al. Assessment of Orofacial Characteristics and Oral naires were fully completed for all pa - sion regarding standardization of the Pathology Associated With Cri-Du-Chat tients, further reducing comparisons. examiners. Syndrome. Oral Dis 2012; 18 (March): 191 –197.

Sleep Apnea in a Special Needs Population Is a Other

Threat to Daily Function 4 - Color Process 4 - Color Process shown to graduallyC a= f7fe1 ct behavior and symptoms. Only 2 of the coC h= o71rt were Take Home Pearl: social interactions Mo f= c29hildren. classified as overweight. M = 29 The obstructive sleep apnea Y = 0 Y = 0 Objective: To asseK s= s3 2 the prevalence Conclusions: In children wK =it h32 rate in a CHARGE syndrome and symptomatology of OSA in a CHARGE syndrome, OSA is a signifi - cohort was 65% compared to CHARGE population. cant threat to daily function. 1% to 4% in the general pedi - atric population. Participants/Methods: Subjects were Reviewer’s Comments: I have been aged 0 to 14 years with a confirmed interested in how sleep disturbances CHARGE diagnosis. Data collected in - affect the special needs population, Background: CHARGE syndrome is cluded demographics, history of previ - and I think it is an underrated and mis - associated with choanal atresia, 1 - Color Gradient ous sleep surveys, Pediatric Sleep understood phenomenon. Children colobomas, cranial nerve abnormali - Black Questionnaire, and OSAS Quality of with special needs have been over - ties, and temporal bone abnormalities. Life Survey. whelmingly shown to have sleep dis - The overall incidence of CHARGE syn - LOGO turbances, and, in the case of drome is 1 in 8,500 births, making it a Results: Data were collected from 51 CHARGE syndrome patienItCsO,N OSA is a common genetic disorder. It has been children, with a mean age of 6 years. significant detractor from quality of life. noted previously that close to 60% of Of the total cohort, 65% had a diagno - Even after CPAP or ENT surgery, 20% children with CHARGE have sleep dis - sis of OSA, and 10 children were of patients still had apneic episodes turbances, including apneic episodes. being treated with continuous positive (note that these patients were over - Some studies have suggested an ob - air pressure (CPAP). The CHARGE whelmingly non-obese). structive sleep apnea (OSA) preva - children exceeded the sleep survey 1 - 1C o- lCoor lSoor lid 1 -1 C -o Cloorl oSrolid lence in CHARGE patients as high as threshold for OSA bBlyac kdouble. Even fol - Black PMS 646 Reviewer: S. Thikkurissy, DPMDSS 64, 6 MS 50% compared to 1% to 4% in the lowing treatment (tonsillectomy and Article Reviewed: Trider CL, Corsten G, general pediatric population. OSA and adenoidectomy), 21% of CHARGE pa - et al. Understanding Obstructive Sleep other sleep disturbances have been tients still had OSA-associated Apnea in Children With CHARGE Syn - drome. Int J Pediatr Ororhinolaryngol 2012; April 25: epub ahead of print.

Keep That Portable X-Ray Unit Battery Charged Other

4 - Color Process 4 - Color Process that tube vol1ta - Cgoelo sr CSh o=oli 7du1 Rldev berese dwithin 10% Pro) is increasing dra1 m- CaoltoicrC Sa o=ll i7yd1 Rinev ersed Take Home Pearl: of indicated kV valMWu e=hi st2e 9 at all times. dentistry. Recently, an FDAMW r=he i2tce9 all re- Not all hand-held x-ray devices Tube voltage was mY =e 0asured with digi - alerted us to the fact that thYe =r 0e is not a K = 32 K = 32 come with backscatter shields. tal sensors and 7 different portable substantial body of literature on these systems. Exposure time was meas - devices, and radiographic precautions Background: Hand-held x-ray equip - ured with differing battery levels all for need to constantly be followed. The ment is designed specifically to be adult mandibular molar periapical radi - premise of this article, namely effect of hand-held during operation. It was first ographs. The tube voltage was meas - battery charge on tube voltage, is not developed in the early 1990s for mili - ured for 3 consecutive exposures. something I had really considered — I just always try to have a charged bat - tary dentistry. Since their first use, they Results: For a1l l- uConloitrs G,r athdienrte was a re - Black tery on hand but do not change out have also been used in areas such as duction in tube voltage (as measured unless it is low. Maybe I should be nursing homes, forensic investiga - in kV). Tube voltage deviation percent - changing them out at the beginning of tions, and temporary healthcare clin - age of the kV ranged from 2.5% to every procedure. ics. Because the operator is in direct 10.0% of indicated kV range. Not all contact with the radiation-emitting models came with a backscatter shield. Reviewer: S. Thikkurissy, DDS, MS source, concerns have been raised Kim EK. Effect of the Conclusions: Portable x-ray equip - Article Reviewed: about backscatter. Amount of Battery Charge on Tube Volt - ment efficacy is affected by amount of age in Different Hand-Held Dental X-Ray Objective: To assess the effect of bat - battery charge. Systems. Imaging Sci Dent 2012; 42 tery charge on tube voltage in different (March): 1 –4. Reviewer’s Comments: This article is hand-held systems. 1 - Color Solid 1 - Color Solid significant in that thBela cpk revalence of Black Methods: Current Korean Food and hand-held units (such as the NOMAD Drug Administration regulators indicate

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1 - Color Solid Reversed 1 - Color Solid Reversed White White LOGO

ICON

1 - Color 1 - Color PMS 646 PMS 646

Does Coffee for Mom Mean a Restless Sleep Risk Assessment

for Baby? 4 - Color Process 4 - Color Process ObjeCc =t 7i1ve: To assess caffeine con - ConclusionCs =: 7C1 affeine consumption Take Home Pearl: sumMp t=i o29n by mothers and infant sleep/ during pregnMa =n 2c9 y and by nursing Caffeine consumption during wakinY g= 0 patterns. mothers seemY =s 0 not to have conse - K = 32 K = 32 pregnancy and by nursing quences on sleep of infants at the age Methods: A birth cohort was assessed mothers seems not to have con - of 3 months. for heavy maternal caffeine consump - sequences on sleep of infants tion (defined as >300 mg/day). Other Reviewer’s Comments: The results at the age of 3 months. assessments included smoking, mari - were not what I expected, but this tal status, family monthly income, and does make sense. There are a con - Background: A child’s sleep habits are maternal depression. stellation of family-based variables often still in flux during early infancy, 1 - ColoLOr GGrO adient that may contribute to waking among ResuBlatcsk : Data were collected from 885 with night waking being a common oc - children, and maternal caffeine alone infants. Caffeine consumption de - currence. There have been associa - is not the “silvICeOrN bullet,” although this creased during gestation, and at 3 tions between more frequent night study does implicate it with some de - months post-partum the mean caffeine waking in children and male gender, gree of causality. The sleep environ - consumption was 144 mg/day. Heavy daytime napping, bed sharing, and ment that the child is in also plays a consumption was reported by 20% of poverty. Caffeine is a central nervous highly significant role in whether the mothers but also decreased with gesta - system stimulant commonly used by child develops good sleeping habits. tion. Night waking was more common adults. Caffeine has been shown to 1 - Color 1 - Color in children where mothers used alcohol cross the placental barrier; furthermore, PMS 646 Reviewer: SP.M TS h64ik6 kurissy, DDS, MS during pregnancy. Infants exposed to Santos IS, Matijase - the fetus has been shown to have a Article Reviewed: hi1g -h Ceorlo r aSotelid s of prenatal caffeine had a vich A, Do1m - iCnoglour eSosl iMd R. Maternal Caf - poor ability to metabolize caffeine. Black Black 9% higher rate of night waking. feine Consumption and Infant Nighttime Waking: Prospective Cohort Study. Pedi - atrics 2012; 129 (May): 860 –868.

Defining the Role of a Pain Clinic in Pediatrics Risk Assessment

4 - Color Process 4 - Color Process DesiCg =n 7/1Methods: This study retro - laryngospasmC ,= a71nd vomiting. Parents Take Home Pearl: specMti v=e 2l9 y evaluated the activities of and children Mw =e r2e9 very satisfied with Common methods used to the PYr o=c 0 edural Pain Service of the their pain cliniYc = p 0 rocedures. K = 32 K = 32 distract children from painful 1 - UConloivr Seorlisdi tRye voerfs ePd adua Department of Pe - 1 - Color Solid Reversed White ConclusionsW: hTite his Italian model func - procedures include cartoons diatrics over a 5-year period from 2006 tions on 2 integrated levels, and it can and bubbles. to 2010. Data were collected on pa - be considered generally applicable as tients, procedures, sedatives, and a solution for pain management. analgesics used. Background: Pain in childhood has Reviewer’s Comments: The pain been associated with short- and long- Results: Over a 1,272-day period, clinic described here is really a seda - term morbidity. It has been shown to 31, -8 C1o5lo rp Garatideienntt s were treated, with a Black tion clinic in the United States. Com - potentially restructure pain pathways, mean of 8.5 sedations/pain-associated mon behavior guidance techniques resulting in altered pain thresholds, management procedures daily. The such as use of distraction are de - which can impact both patient and par - median age of patients treated was 6 scribed and shown (as we know) to be ent treatment compliance. Procedure- years. Over 40% of patients had >1 effective for children. The adverse ef - related pain is a significant cause of procedure associated with the pain fects match those reported in the den - pain in childhood, and this may include clinic. The most common procedures tal literature. inadequate periprocedural analgesia performed were lumbar puncture and and postoperative pain recognition bone marrow aspiration. Patients were Reviewer: S. Thikkurissy, DDS, MS and management. distracted during sedations with the use Article Reviewed: Po C, Agosto C, et al. of cartoons in 40% of sedations and Procedural Pain in Children: Education Objective: To evaluate a procedural 1 - Color Solid and Manag1e - mCoelonr tS.o Tlid he Approach of an bubblBelasc k in 30% of sedations. The most Black pain service’s role in pain manage - Italian Pediatric Pain Center. Eur J Pedi - common adverse events associated ment and education. atr 2012; March 7: epub ahead of print. with sedations included desaturation,

1 - Color Solid Reversed 1 - Color Solid Reversed White White

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in Pediatric Dentistry quiz Vol. 26 No. 1 Literature review and critical analysis from the publisher of Practical Reviews

To receive credit for this activity, answer the practice 11. School-based fluoride rinse programs are very effec - quiz questions below, read the content, and complete the tive and cost effective. online post activity quiz at www.practicalreviews.com. Log in using your email address and password, click on Practice: T F Answer Submitted: T F “Take a Quiz,” and enter the e-quiz code located below . 12. Trider et al found that treatments were 100% effec - E-quiz code: 31885N tive in reducing obstructive sleep apnea in the CHARGE syndrome population. 1. Increasing age lowers caries risk. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F 13. Autistic children are very good at picking up on non- 2. Schwartz et al found that exposing dental students verbal behavior cues. to videos of real patients sharing their negative den - Practice: T F Answer Submitted: T F tal experiences did not increase empathy toward pa - tient concerns. 14. According to Santos et al, infants exposed to higher rates of prenatal caffeine have higher nighttime Practice: T F Answer Submitted: T F waking. 3. Microabrasion is the best method for the cosmetic Practice: T F Answer Submitted: T F treatment of post-orthodontic demineralized white spot lesions. 15. Oral appliances have been demonstrated to have clinical efficacy rates similar to continuous positive Practice: T F Answer Submitted: T F airway pressure, but are often preferred due to being 4. Ankylosis and infraposition of the crown can occur less invasive. when bone invades the pulp canal space. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F 16. Portable x-ray equipment efficacy is affected by 5. Pitts et al found that rinsing after tooth brushing re - amount of battery charge. duces the clinical efficacy of the fluoride effect. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F 17. Park et al found a demonstrated association between 6. In the study by Claus et al, the risk for meningioma reduced drooling and improved sleep habits in cere - was greater in adults because they were more likely bral palsy patients. to have been exposed to panoramic radiographs. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F 18. Maternal sleep disturbances have no association 7. The study by Rodriguez-Caballero et al found that with maternal depression. 94% of patients with cri-du-chat syndrome were di - Practice: T F Answer Submitted: T F agnosed in infancy from a monotone weak cat-like cry. 19. In an Italian study by Po et al, the authors found Practice: T F Answer Submitted: T F that the most common adverse event associated with 8. According to Hunt et al, aromatherapy agents are sedation in their pain clinic was oxygen desaturation. ineffective as a treatment for postoperative nausea. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F 20. Gonzalez et al found that overall mortality rates as - 9. Leal et al found that children with toothaches or ex - sociated with anesthesia are low, but the main con - tractions had 6 times the likelihood of reduced qual - tributing factor is the child’s underlying disease and ity of life. not the anesthesia itself. Practice: T F Answer Submitted: T F Practice: T F Answer Submitted: T F

10. Many drugs used for pediatric patients during anes - thesia lack FDA labeling for pediatric use. Practice: T F Answer Submitted: T F

14 ™ presents

in Pediatric Dentistry answers Vol. 25 No. 12 Literature review and critical analysis from the publisher of Practical Reviews

1. T High concentrations of fluoride found in 2,500 11. T The combined application of iodine followed by ppm fluoride toothpaste can be “stopped’ by fluoride varnish reduces new tooth decay by bacteria. 31% overall, according to a recent study.

2. T The revascularization technique is effective in 12. F It is estimated that nearly 90% of parents re - limiting the inflammatory external root re - ceive evidence-based recommendations on paci - sorption in the replanted incisor. fier usage.

3. F Occupational exposure doses for handheld x- 13. F Patients who are treated with the Ankaferd ray systems are significantly more than for blood stopper (ABS) for hemostasis control wall-mounted systems. have significantly more postoperative infec - tions than those not treated with the ABS. 4. F Systemic antibiotics are no longer indicated in the treatment of avulsed permanent teeth. 14. T In a population of cerebral palsy patients, the primary injection site for botulinum toxin is 5. T Prenatal counseling of high-risk mothers may lower limbs. reduce the risk for future oral disease in their offspring. 15. F Adequate hemostasis can be achieved through routine transfusions in patients who are taking 6. F Children whose racial background is non-His - multiple antiplatelet agents. panic white are at increased risk for obesity and early tooth eruption. 16. F Males and females are equally diagnosed with attention deficit/hyperactivity disorder. 7. T The recent retrospective study by Elangovan et al found that >80% of patients who visit the 17. F The reported bioavailability of oral midazolam emergency department for herpetic gingivos - is close to 100%. tomatitis are treated and routinely discharged, with 15% requiring hospitalization. 18. T Younger children with earlier onset of epilepsy have worse behavior issues than do children 8. F Both race and socioeconomic status have an ef - with a later onset. fect on the diagnosis and reporting of child abuse. 19. T Unmodified rosin exposure may sensitize pa - tients to all forms of rosin, including modified 9. F Loupes are absolutely necessary for accurate rosin. occlusal caries lesion detection. 20. T There are no differences in postoperative pain, 10. F Under the new immunization schedule, only amount of rescue analgesia, or oral intake of girls should receive the human papilllomavirus food between patients who receive intraopera - quadrivalent vaccine. tive dexamethasone and those who do not.

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