Prevention of dental disease. The role of the pediatrician

Evidence increasingly suggests that to be successful in preventing dental disease, we must begin preventive interventions within the first year of life. Pediatricians are well positioned to begin this process with early assessment of oral health and provision of anticipatory guidance, including ensuring that patients establish a dental home in addition to their medical home. This article provides information that will enable pediatricians to assess caries risk and provide practical and effective advice to parents about preventing dental disease, including oral hygiene, diet, and fluoride recommendations.

Stentless aortic valve replacement with Freestyle or Toronto SPV: an early comparison

BACKGROUND

Stentless aortic xenograft valves have been developed to overcome the disadvantages of conventional stented prostheses. We have implanted two new aortic bioprostheses: the Medtronic Freestyle and the St. Jude Toronto SPV. Early results are compared.

METHODS

Forty-four Freestyle valves were implanted using a freestanding total root technique. Fourteen subcoronary Toronto SPV bioprostheses were implanted. Sixty-four percent of both groups (28 of 44 Freestyle and 9 of 14 Toronto SPV) underwent concurrent procedures.

RESULTS

Ischemic time was 117 +/- 21 minutes for Freestyle and 124 +/- 19 minutes for Toronto SPV. There were no operative deaths or valve-related reoperations. Aortic valve area was 1.83 +/- 0.51 cm2 for Freestyle and 1.80 +/- 0.51 cm2 (p = 0.89) for Toronto SPV. Transvalvular gradient was 8.03 +/- 4.09 mm Hg for Freestyle and 12.4 +/- 1.82 mm Hg (p = 0.002) for the Toronto SPV. Aortic regurgitation was not experienced in any Freestyle patients, while Toronto SPV patients were graded as none to trace 79% (11 of 14), mild 14% (2 of 14), and moderate 7% (1 of 14).

CONCLUSIONS

Aortic valve replacement with the Freestyle and Toronto SPV required equal time for implantation and had equal effective orifice areas. Freestyle had lower transvalvular gradient and less aortic insufficiency without increasing morbidity or mortality.

Overview of the history and current status of fluoride supplementation schedules

Clinical trials of dietary fluoride supplements began in the 1940s in an effort to bring the benefits of fluoride to those who did not receive it through their drinking water. Following the early success of these trials, the Council on Dental Therapeutics of the American Dental Association (ADA) published its first recommendations for fluoride supplementation in 1958. The American Academy of Pediatrics (AAP) followed with its own recommendations in 1972. During the 1970s a variety of alternative schedules appeared in the literature, most in reaction to the findings of unexpectedly high levels of enamel fluorosis in children being supplemented with the AAP schedule. In 1979 the ADA and AAP agreed on essentially identical schedules. During the 1980s, however, the prevalence of enamel fluorosis continued to increase, and fluoride supplements were found in some studies to be a risk factor for fluorosis. This finding prompted another round of dosage schedule recommendations in the early 1990s. This paper presents a history of fluoride dosage recommendations and reviews the recent proposals for reducing supplement dosage.

The Ace Bandage approach to digit-sucking habits

This article describes an at-home program to assist children with nocturnal digit-sucking habits. Children with such habits are candidates for this program if they wish to discontinue their habits and have no psychological contraindications for habit cessation. The program involves nightly use of an elastic bandage wrapped across the elbow. Pressure exerted by the bandage removes the digit from the mouth as the child tires and falls asleep. Careful patient selection and parent education can lead to a success rate that makes the program worth attempting prior to instituting appliance therapy.

Comparison of results using "freestyle" stentless porcine aortic root bioprosthesis with cryopreserved aortic allograft

Aortic valve replacement with natural heart valves offer the advantages of superior hemodynamics, laminar flow patterns, lack of need for anticoagulation, and perhaps improved durability. This study compares 5-year results for two stentless aortic valves. In 1992, two prospective clinical trials using two different stentless aortic valves were initiated at our center. The Freestyle stentless porcine aortic root bioprosthesis (SPB) was placed in 106 patients, and cryopreserved aortic allografts (CAA) were placed in 174 patients using a freestanding total root replacement technique in each series. The mean systolic gradient for the SPB was 7.5+/-4.4 mm Hg at discharge and 5.9+/-3.1 mm Hg at 5 years. The mean systolic gradient for the CAA was 6.4+/-3.3 mm Hg at discharge and 5.0+/-2.2 mm Hg at 5 years. At discharge 92.2% of SPB patients had no aortic insufficiency (AI) and 7.8% had trivial AI. In all, 92.9% of CAA patients had no AI at discharge, and 7.1% had mild AI. At 5-year follow-up, 100% of the SPB had no AI, and only 20% of the allograft patients had no AI. The remainder, 80%, had mild AI. Excellent hemodynamic function was seen with both SPB and CAA. A lower incidence of nonhemodynamically significant AI was observed in the SPB group. Preoperative factors such as chronic renal failure and endocarditis may have adversely affected durability in the allograft group, but long-term follow-up is still required to determine durability.

Fluoride in whole saliva, parotid ductal saliva and plasma in children

The purpose was to investigate the relation between fluoride concentrations in whole saliva, parotid ductal saliva, and plasma in 5- to 10-year-old children (n = 17). Two stimulated whole-saliva samples were obtained from each child. Before the second sample was obtained, each child rinsed several times with a total of 100 ml of deionized water. Parotid saliva samples were obtained by use of a Lashley cup. Fluoride concentrations were determined by fluoride ion-specific electrode after diffusion with hexamethyldisiloxane. Rinsing with deionized water did not significantly reduce the fluoride concentration in whole saliva. The whole-saliva fluoride concentrations were not significantly related to those in plasma or parotid ductal saliva. Parotid fluoride concentrations, however, were significantly related to plasma fluoride concentrations (p < 0.0001) by a proportionality constant of 0.80. It was concluded that parotid salivary fluoride concentrations can be used to estimate plasma fluoride concentrations in 5- to 10-year-old children.

Aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis

BACKGROUND

Stentless porcine prosthetic valves offer several advantages over traditional valves. Among these are superior hemodynamics, laminar flow patterns, lack of need for anticoagulation and perhaps improved durability.

METHODS

One hundred and twelve patients were operated on from September 17, 1992 to April 13, 1998 as part of a multi-center worldwide investigation. All patients received a total aortic root replacement. Patients were evaluated postoperatively at discharge, 3 to 6 months, and yearly by clinical exam and color flow Doppler echocardiography.

RESULTS

There were 4 deaths either in the hospital or within 30 days after surgery for an operative mortality of 3.6%. No patients experienced structural valve deterioration, non-structural valve deterioration, paravalvular leak, unacceptable hemodynamic performance, or postoperative endocarditis. The linearized rates for survival and thromboembolic complications at 5 years were 82.8% and 90.5% respectively. Excellent hemodynamic function is demonstrated by very low gradients, large EOA, and an exceedingly low incidence of any aortic regurgitation.

CONCLUSIONS

The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root for aortic valve and aortic root pathology. Root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Early and intermediate results are encouraging, but further follow-up is needed to determine valve durability.

Dental caries and fluorosis among children in a rural Georgia area

PURPOSE

This IRB-approved study compared the caries experience, fluorosis prevalence, and plaque and salivary fluoride concentrations ([F]) in middle school (MS; N = 51) and elementary school (ES; N = 144) children residing in nonfluoridated and fluoridated communities in rural Georgia. All participants were exposed to fluoridated water at school (0.5-1.2 ppm), some received that level at home, and others received home water with < 0.1 ppm F.

METHODS

Subjects' parents completed a questionnaire regarding fluoride exposure. Children were examined at school by two calibrated dentists.

RESULTS

No significant differences were seen in DMFS+dfs between children with or without fluoridated home water, nor for those with or without fluorosis. MS children with non-fluoridated home water had lower mean salivary [F] values than MS children with fluoridated home water. No differences were found among MS and ES children in mean plaque [F] for those with or without fluorosis.

CONCLUSIONS

Home water fluoridation had little effect on the variables measured. These findings appear to be due to fluoride exposure from fluoridated dentifrices, fluoridated drinking water at school, and the fluoride "halo" effect.

The role of fluoride mouthrinses in the control of dental caries: a brief review

Fluoride mouthrinses have generally proved to be effective in controlling caries in clinical studies. Caries reductions in North American studies have averaged about 30%. Large-scale school-based mouthrinse programs conducted during the 1970s, however, used historical controls at a time when caries rates were now known to be declining. Post-hoc analysis of the absolute (not relative) caries reductions in these studies showed that school-based fluoride mouthrinse programs were of questionable benefit from a cost standpoint. Fluoride mouthrinses have been shown to reduce demineralization and enhance remineralization of enamel adjacent to orthodontic bands and brackets. Benefits in adults have been less well documented. Use of fluoride mouthrinses by young children is discouraged until they have mastery of their swallowing reflexes. This paper recommends the use of fluoride mouthrinses for patients at increased or high risk for dental caries, but cautions that school-based programs be undertaken only in communities with a high population caries rate.

Ultraconservative and cariostatic sealed restorations: results at year 10

Changes in restorative techniques and the development of newer restorative materials have allowed for the use of more conservative cavity preparations. This 10-year study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations. The results indicate that both types of sealed restorations exhibited superior clinical performance and longevity compared with unsealed amalgam restorations. Also, the bonded and sealed composite restorations placed over the frank cavitated lesions arrested the clinical progress of these lesions for 10 years.

Clinical evaluation of new designs for intraoral fluoride-releasing systems

PURPOSE

Intraoral fluoride-releasing (IFR) devices provide elevated levels of fluoride in the mouth for extended periods of time. However, retention and protection of the devices have posed major challenges for clinical applications. The objectives of this study were to develop new methods for retaining and protecting IFR devices in the mouth and to assess their effects on salivary fluoride levels and distribution in adolescents.

METHODS

Four different IFR systems (combinations of an IFR device and its retainer) were evaluated in four groups of 10 adolescents each, 12-15 years of age, for a period of six months. Each child wore two IFR systems of a given type affixed to the buccal surface of each permanent maxillary first molar. Unstimulated saliva samples were collected at each clinical examination and analyzed for fluoride.

RESULTS

A significant increase in salivary fluoride concentration from a baseline mean of 0.07-0.69 microgram/mL was observed on day 14 postinsertion. IFR system retention was 85% after 6 months and, of the systems retained, 100% were functional.

CONCLUSIONS

These findings suggest that IFR devices can be successfully protected and retained in the mouth for prolonged periods of time.

Demographic, educational, and experiential factors associated with dentists' decisions to report hypothetical cases of child maltreatment

The purpose of this study was to examine demographic factors associated with dentists' decisions to report hypothetical cases suggestive of child maltreatment. Surveys were mailed to 500 general dentists (GDs) in Georgia and all 200 pediatric dentists (PDs) in Georgia and Florida. The general dentists were chosen from a pool of 1500 by a stratified randomization scheme. Each survey contained two brief vignettes suggestive of, but not conclusive for, child neglect and abuse. Respondents were asked about their likelihood of reporting each vignette. General demographic questions were asked about the population served by the dentist, the year of dental degree and speciality certificate acquisition, and gender of the respondent. Further questions were asked about the individual's exposure to continuing education in child maltreatment, knowledge of legal requirements to report and the agency to which reports should be directed, and experience with suspected and filed cases. Responses were received from 185 GDs (37%) and 103 PDs (51.5%), a total of 288 (41.4%). PDs had more practitioners in larger communities and had more female respondents. PDs were more likely to answer yes to the questions about education/experience with child maltreatment. Factors associated with likely reporting of neglect were: 1) serving communities with populations < or = 100,000; 2) PDs acquiring specialty certificates after 1980; 3) being female; 4) exposure to continuing education; 5) having suspected cases in practice; and 6) having filed a maltreatment report. Factors associated with likely reporting of abuse were: 1) PDs acquiring specialty certification after 1980 and 2) self-reported recognition of the legal obligation to report.

Perceptions associated with dentists' decisions to report hypothetical cases of child maltreatment

The purpose of this study was to examine case-specific perceptions associated with dentists' decisions to report hypothetical cases suggestive of child maltreatment. Surveys were mailed to 500 general dentists (GDs) in Georgia and all 200 pediatric dentists (PDs) in Georgia and Florida. The GDs were chosen from a pool of 1500 by a stratified randomization scheme. Each survey contained two brief vignettes suggestive of, but not conclusive for, child neglect and abuse. Identical questions followed each vignette that were designed to assess five perceptions of the incident and whether the respondent would be likely to report the case. Responses were received from 185 GDs (37%) and 103 PDs (51.5%), for a total of 288 (41.1%). A majority of respondents considered each vignette to be serious, but only a minority believed that they were required to report the neglect (7.3%) and the abuse (33.7%) vignettes. The percentages of likely reporters of the neglect (n = 28) and abuse (N = 103) vignettes were 9.7 and 36%, respectively. No significant differences were noted in the response patterns of GDs and PDs. Decisions to report child maltreatment described in the vignettes were associated with perceptions of 1) the seriousness of the incident, 2) the incident being defined as neglect or abuse, and 3) a requirement to report. The possibility that a maltreatment report would have a negative impact on the child was associated with a decision not to report. The perception that a report would have a negative impact on the family was common among likely reporters and nonreporters.

Comparison of the use of a child and an adult dentifrice by a sample of preschool children

The purpose of this study was to compare the use of a child dentifrice (CD) and an adult dentifrice (AD) by a convenience sample of preschool-aged children. Fifty participants, ages 31 to 60 months, were recruited from a dental school clinic and an area day care center. All were healthy, free of developmental delays, and capable of applying dentifrice to a toothbrush. The study employed a crossover design in which the children each brushed their teeth twice, once with each type of dentifrice. The order of dentifrice use was assigned randomly, and the two brushings were separated by at least 1 week. The following were recorded: 1) the amount of dentifrice applied, 2) the time spent brushing, and 3) whether the child expectorated and/or rinsed after brushing. The mean weight of CD the children used (0.689 g, 0.43 SD) was significantly greater than that of AD (0.509 g, 0.41 SD, P = 0.02, Wilcoxon's signed rank test). The mean time spent brushing with CD (83.56 sec, 85.4 SD) was significantly greater than for AD (57.48 sec, 39.0 SD, P = 0.01). A "risk factor" (dentifrice weight x usage time) was derived to estimate the relative fluoride exposure of each child. The mean risk factor for CD (58.54, 64.8 SD) was significantly greater than that for AD (27.43, 25.0 SD, P < 0.001). Most children did not expectorate or rinse after brushing. Most parents selected drawings on a questionnaire that indicated that their child routinely used 0.25-0.5 g of dentifrice per brushing, which underestimated the amount they used in the study. The results of this study indicated that young children may be exposed to more fluoride for a longer period of time with CD.

Randomized clinical trial of the effect of prenatal fluoride supplements in preventing dental caries

This randomized, double-blind study tested the caries-preventive efficacy of prenatal fluoride supplementation in 798 children followed until age 5. Initially, 1,400 women in the first trimester of pregnancy residing in communities served by fluoride-deficient drinking water were randomly assigned to one of two groups. During the last 6 months of pregnancy the treatment group received 1 mg fluoride daily in the form of a tablet and the control group received a placebo. Both treatment and control subjects were encouraged to use postnatal dietary fluoride supplements. Caries was measured in children at age 3 and 5 while fluorosis was assessed at age 5. Caries activity was very low in both study groups: 92% of children remained caries-free in the treatment group and 91% remained caries-free in the placebo group. Fluorosis was observed in 26 subjects, all classified as very mild. Overall, there were no statistically significant differences in the study groups with respect to caries and fluorosis in deciduous teeth. The study had sufficient power to detect an absolute risk reduction of 5.1% while only a 1.5% reduction was observed. These findings do not support the hypothesis that prenatal fluoride has a strong caries-preventive effect.

An outcomes assessment of 15 years of patient care experiences in predoctoral pediatric dentistry

The purpose of this study was to examine the trends in numbers, demographic characteristics, and treatment history of pediatric dental patients under the care of dental students over the period 1980 through 1994. Data were collected for: exams, sealants, surfaces of amalgam, composite resin surfaces, pulpotomies, stainless steel crowns, and extractions. Correlations were done across the 15-year period to determine significant trends over time. During the 15-year period, the average number of patient visits required for each student to complete the requisite number of patients, declined from 45 appointments to complete 10 patients in 1980, to 35 visits to complete 13 patients in 1994. Over time, the numbers of amalgam surfaces, pulpotomies, extractions and stainless steel crowns decreased significantly, while the number of composite resin surfaces increased (P < 0.05). Based on a previous outcome assessment that indicated declining numbers of procedures performed between 1980 and 1985, the required number of patients treated per student was raised from 10 to 13, beginning with the 1986 class.

Effects of current and former pacifier use on the dentition of 24- to 59-month-old children

Two hundred eighteen children ages 24-59 months participated in a study to examine the effect of pacifier use on the occlusion of the primary dentition. A questionnaire was used to gain information on habit history. Eighty-two children were current or former users of functional exercisers, 38 had a history of conventional pacifier use, and 98 had no history of oral habits. Compared to children with no habit, those with a history of pacifier use had a significantly larger mean overjet (P < 0.001), as well as significantly higher occurrences of Class II primary canines (P = 0.015), distal step molars (P = 0.014), openbite (P = 0.001), and posterior crossbite (P = 0.025). Compared to users of conventional pacifiers, users of functional exercisers had a significantly higher occurrence of Class II primary canines (P = 0.013) and distal step molars (P = 0.037). Pacifier use time in months was significantly higher for children with openbite (P = 0.02) and posterior crossbite (P = 0.019). Compared to former pacifier users, those with current habits had a significantly higher prevalence of openbite (P = 0.002) and posterior crossbite (P = 0.001), and a greater mean openbite (P = 0.19). The reported number of hours use per day was not related to any aspect of the occlusion of pacifier users. African-American and European-American children began their habits at about the same age and used their pacifiers for an equivalent number of hours per day. Among those who had discontinued their habits, African-American children had maintained theirs for a significantly shorter period (P < 0.001), leading to a longer elapsed time between habit discontinuation and the examination.

Enamel uptake and patient exposure to fluoride: comparison of APF gel and foam

This crossover study with 46 child dental patients compared two topical APF products, a gel and a foam, with respect to the amounts of product and fluoride (F) applied, salivary F concentrations, and enamel F uptake. Half the subjects were treated for 4 min with the gel first and the other half with the foam. After approximately 16 days, each patient received a second treatment using the other product. An acid-etch enamel biopsy was performed and whole saliva samples were collected before and after each treatment. Significantly less F was applied to the teeth and retained by the subjects when the APF foam was used. Salivary F concentrations after treatment with the gel were higher than after treatment with the foam. The differences in enamel F uptake at both 15 min and 16 days after the APF applications, however, were not significant. We concluded that: 1) the two products are equivalent with respect to enamel F uptake; 2) only about one-fifth as much of the foam product is required for adequate coverage of the teeth, which significantly reduces F exposure and retention by the patient.

Cariostatic and ultraconservative sealed restorations: nine-year results among children and adults

The objective of this clinical study was to evaluate the long-term efficacy of placing sealed posterior composite restorations for arresting active caries. The tooth preparation for this bonded and sealed restoration was limited to placing a bevel in the enamel only, without the removal of the carious lesion. The radiographic and clinical performance of these ultraconservative sealed composite restorations placed over caries (CompS/C) was compared over a period of nine years with: 1) ultraconservative, localized sealed amalgam (AGS) restorations with no extension for prevention, and 2) traditional, unsealed amalgam restorations (AGU) with the usual extension for prevention outline form. Sealant retention with > 50 percent to 100 percent of the margins occurred in 64 percent of CompS/C and 82.5 percent of AGS restorations. After nine years the cumulative failure rates were 16 percent for CompS/C, 2.5 percent for AGS, and 17.1 percent for AGU restorations. Thus, the clinical performance of CompS/C restorations was slightly superior to that of the traditional AGU restorations. The AGS restorations were definitely superior to the traditional AGU restorations and to the CompS/C restorations in both children and adults alike. Complete sealant retention over CompS/C and AGS restorations was equivalent between children and adults (P = 0.14 and 0.74, respectively). A higher percentage of open margins in CompS/C restorations was seen, however, in children (17.4 percent) than adults (1.94 percent). This study has shown that Class I caries can be arrested by the CompS/C restoration.

In vitro effect of human saliva on the output of fluoride from controlled-release devices

This study was designed to determine the in vitro fluoride output from controlled-release devices in stimulated, whole human saliva, and to assess changes in the salivary calcium concentration following immersion of the devices. Twenty fluoride (F) controlled-release devices of the hydroxyethyl methacrylate (HEMA)/methyl methacrylate (MMA)-type were employed. Each was designed to release 1-2 mg F per day. All devices were placed individually in 10.0 ml of deionized water for 3 days to assess baseline F output. Seven devices with markedly high or low output were discarded. During days 4-13, three of the remaining 13 devices were placed individually in 10.0 ml of stimulated, whole saliva donated by three volunteers. All devices were returned to deionized water during days 14-17. All solutions were replaced daily with fresh solutions, and each test tube was inverted once every 24 hr. The study was conducted at 19-21 degrees C. Fluoride concentration of the deionized water and human saliva was assessed by ion-specific electrode; calcium concentration of the saliva was assessed pre- and postimmersion by flame atomic absorption spectrometry. The fluoride output of the devices placed in saliva decreased to 36% of their baseline rates (P < 0.001). The calcium concentration of the human saliva decreased from a mean preimmersion value of 3.58 mg/100 ml (+/- 0.63 SD) to a postimmersion value of 2.64 (+/- 1.12 SD; P < 0.001). These results suggest an interaction between the fluoride released by the devices and calcium in the saliva.(ABSTRACT TRUNCATED AT 250 WORDS)

Pit and fissure sealant application using a drying agent

This clinical investigation assessed the retention of pit and fissure sealants with and without the use of a post-etching drying agent in pediatric dental patients. Twenty eight healthy patients with four fully erupted, non-carious first permanent molars participated. Sixteen males and 12 females, 5-12 years of age, each received four sealants, two with and two without a drying agent. Sealants were placed by three dental operators. Assignment for sealant application (with and without drying agent) was based on a computer-generated randomization table. Sealant application involved cleansing of the teeth with a non-fluoridated prophylaxis paste followed by rinsing 60 seconds with air/water spray, enamel conditioning with 40% phosphoric acid for 60 seconds, rinsing with air/water spray for 60 seconds, application of drying agent for 5 seconds, application of sealant material, and light curing for 60 seconds. Modified USPHS (Ryge) criteria were used to evaluate interfacial staining, secondary caries, marginal integrity, and surface texture. Sealant retention was evaluated as fully retained or lost (failed). All 28 participants returned for the 12-month recall visit. Four evaluators reported a 91% overall retention rate. Of the 56 teeth sealed without a drying agent, there was a 13% (n = 7) failure rate compared to 5% (n = 3) failure rate for the 56 teeth sealed with a drying agent. These results were not statistically significant (P > 0.05) based on the log-rank test.

Interexaminer agreement for readings of dip slide tests for salivary mutans streptococci and lactobacilli

This study reports the interexaminer agreement of three pairs of evaluators of salivary dip slide tests for mutans streptococci and lactobacilli. 717 Cariescreen SM and Bactotest LB dip slides were available for assessment by 2 dentists and 1 dental hygienist. A single calibration session was held prior to the onset of the study. Each dip slide was read once by each examiner independently. Among the three pairs of examiners, Pearson R values ranged from 0.84 to 0.90 for Cariescreen and from 0.78 to 0.87 for Bactotest. Kappa statistic values ranged from 0.56 to 0.61 for Cariescreen and from 0.70 to 0.74 for Bactotest. The range of agreement was from 72.2 to 76.9% for Cariescreen and from 86.4 to 88.3% for Bactotest. The majority of disagreements were of one category in magnitude, though there were a few disagreements of greater magnitude. This study found moderately strong agreement among the three examiners; it suggests that multiple examiners of dip slide tests carefully calibrated initially and periodically to ensure a high level of agreement.

Effect of artificial saliva and calcium on fluoride output of controlled-release devices

The purpose of this in vitro study was to assess the effect of graded concentrations of calcium in artificial saliva on the output of fluoride from HEMA/MMA controlled-release devices. After the initial release rates were determined in deionized water, the devices were assigned to five groups. The devices of one group remained in deionized water throughout the 19-day study while those of the other groups were placed in artificial saliva containing 0, 4.5, 8.0, or 12.0 mg% calcium on days 4-13. Ten devices of each group were placed in deionized water again on days 14-17 and then in 0.1 mol/l HCl on days 18-19. The five devices of each group that were not placed in deoinized water on day 14 were inspected for surface crystals and then placed in 1 mol/l KOH for 2 days. The fluoride release rates in artificial saliva were reduced by 71-90% and in proportion to the calcium concentration. The release rates in deionized water (days 14-17) approached the baseline values; they exceeded baseline rates by 13-49% while in HCl. The fluoride release rates did not differ among the groups while in KOH, but calcium output was directly related to the calcium concentration of the artificial saliva. The results indicate that fluoride release from HEMA/MMA devices is markedly reduced in artificial saliva and that the reduction is proportional to the concentration of calcium.

Association of generalized joint hypermobility with history, signs, and symptoms of temporomandibular joint dysfunction in children

This study determined the prevalence of signs and symptoms of temporomandibular joint dysfunction (TMD) in children with and without generalized joint hypermobility (GJH). Twenty children with GJH, ages 4-19, and 20 age- and sex-matched control children completed a TMD signs/symptoms history and underwent an examination consisting of palpation of the joints and associated musculature for tenderness, clicking, or crepitation. Children with historical or clinical findings were designated positive for TMD signs/symptoms. Maximum vertical opening, expressed as a percentage of lower facial height, and maximum mandibular lateral excursion (in mm) were recorded. Fifteen (75%) of the GJH participants and ten (50%) of the controls were positive for TMD findings. There were statistically significant differences between the groups for the presence of total positive findings (P < 0.001) and for responses to palpation of muscle or joint (P = 0.03). There were no significant differences in positive responses to the history alone, joint palpation alone, or muscle palpation alone. There were no significant differences between the groups in jaw excursions. This study suggests that children with GJH may be more likely to demonstrate some signs and symptoms of TMD than children with normal joint mobility.

Oxygen saturation and diffusion hypoxia in children following nitrous oxide sedation

Oxygen saturation of arterial blood (SaO2) was assessed in children after discontinuing N2O/O2 sedation for dental procedures. Two post-treatment methods were used: breathing 100% O2 for 5 min after the procedure, and breathing room air for 5 min. Participants were 24 healthy children ages 41 to 113 months. Each child was treated twice and a crossover design was used. The mean length of procedures that were followed by O2 was 28.8 (+/- 10.9 SD) min; for those followed by room air, 28.3 (+/- 12.4 SD) min. SaO2 was monitored continuously by pulse oximetry and recorded at predetermined intervals before, during, and after N2O/O2 administration. When participants received post-treatment O2, the mean SaO2 at 1 min after N2O cessation (99.91 +/- 0.63 SD) and 5 min after cessation (99.94 +/- 0.17 SD) was statistically significantly higher than the pretreatment value of 99.28 (+/- 0.63 SD). When participants received post-treatment room air, the mean SaO2 1 min after N2O cessation (99.44 +/- 0.8) was also statistically significantly higher than the pretreatment mean (99.08 +/- 0.96). After 2 min, however, the mean SaO2 decreased and was statistically indistinguishable from the pretreatment level after 5 min (99.13 +/- 0.9 SD). Fluctuations in SaO2, though statistically significant, were less than 1%. Allowing children to breathe room air immediately after cessation of N2O/O2 inhalation did not reduce SaO2 below clinically acceptable levels. This study further documents the safety of N2O/O2 sedation, and gives the clinician additional information concerning the safe and effective administration of inhalation sedation. (Pediatr Dent 15:88-92, 1993).

Caries risk assessment in a longitudinal discrimination study

Our objective was to develop and perfect a model for the assessment of risk of dental caries onset in children. Even though dental caries prevalence in children is continuing to decline, there is still a significant minority for whom it is a problem. In this study, we sought to ascertain whether a set of variables selected in a previous cross-sectional study could be used to differentiate between caries-free six-year-olds who would or would not subsequently present with clinically-detectable caries. A total of 472 caries-free six-year-olds--286 from a fluoridated community and 186 from a fluoride-deficient community--was selected. Clinical examinations for DMFS, dental fluorosis, and plaque were conducted. Stimulated whole saliva was collected for analysis of mutants streptococci, lactobacilli, total viable flora, and fluoride, calcium, and phosphate concentrations. A questionnaire was used for collection of demographic data as well as information on prior fluoride exposure, dietary habits, and oral hygiene practices. By means of linear discriminant analyses, it was possible to predict correctly which children would develop caries within six to 12 months (sensitivity) in 82.8% of cases and which children would not develop caries during that period (specificity) in 82.4% of cases.

Caries risk assessment by a cross-sectional discrimination model

Although the prevalence of dental caries is continuing to decline, it still affects a majority of the US population and can be a serious problem for those afflicted. The objective of this project was to develop and perfect a model for assessment of risk of dental caries onset in children. In the first study, reported herein, a set of clinical, microbiological, biochemical, and socio-demographic variables was identified that distinguished, with an acceptable level of sensitivity and specificity, between children who had no previous caries experience and children who had high caries levels. A total of 313 children--age 12-15 years, 140 from a fluoridated community and 173 from a fluoride-deficient community--was selected on the basis of previous caries experience, either zero DMFS or high DMFS (> or = 6 in the fluoridated or > or = 8 in the fluoride-deficient community). Clinical exams for DMFS, dental fluorosis, and plaque were conducted. Stimulated whole saliva was collected for analysis of mutans streptococci, lactobacilli, total viable flora, and fluoride concentration. A questionnaire was used for collection of demographic data as well as information on prior fluoride exposure, dietary habits, and oral hygiene practices. By means of discriminant analyses, with use of seven key clinical and laboratory variables, it was possible for zero-DMFS subjects to e classified correctly (specificity) in 77.6% of cases in the fluoridated community and in 86.1% of cases in the fluoride-deficient community. High-caries subjects were classified as such (sensitivity) in 79.3% and 88.1% of cases, respectively.

Evaluation of the effects of orthodontic pacifiers on the primary dentitions of 24- to 59-month-old children: preliminary study

This study was designed to compare the occlusions of 24- to 59-month-old children who used orthodontic or conventional pacifiers to the occlusions of a group of controls who had no sucking habits. Information on the habits was collected by parental questionnaires. Ninety-five children were examined for malocclusions involving overbite, overjet, canine, and molar relationships, and posterior crossbites. Users of orthodontic pacifiers had statistically significantly greater overjets, and there was a significantly higher proportion of subjects with open bite in the conventional pacifier group. There was a trend toward a greater number of subjects in the control and orthodontic pacifier group with overbites less than or equal to 50%. These differences were not clinically significant, however. There appeared to be only minor differences between the occlusions of the two pacifier groups.

Practical clinical applications of sports dentistry in private practice

Preparing a practice to become "trauma-ready" involves more than educating the dentist and the staff in the proper management of dentofacial trauma. All members of the office should understand their roles in preventing and treating trauma. They must be willing to provide care after hours when called upon to do so. Dentists who want to be more involved might wish to volunteer their services as sports dentists for local school or recreational league teams. The dentist who is conscious of his or her patients who are at risk for sports-related trauma will also find others in the practice who might benefit from many of the same protective devices that are being constructed for athletes. These include children involved in higher-risk activities, developmentally disabled patients, patients undergoing general anesthesia, and others. Being trauma-ready may open up several rewarding activities for the practice because of the many spin-off applications. The trauma-ready practice must also be cognizant of the some-times perplexing legal and insurance issues with regard to preventing and treating sport-related injuries. In addition to lowering the risk exposure to the practice, the dentist can help ensure the maximum third-party benefits for the patient.

Current fluoride therapy in dentistry for children

The literature on fluoride therapy for children continues to document the effectiveness of systemic and topical delivery in reducing dental caries in the recipients. The value of optimally fluoridated water supplies continues to be confirmed, but studies reflect a growing concern for an increased prevalence of very mild and mild enamel fluorosis in both optimally fluoridated and fluoride-deficient communities. Studies document the need to educate health care professionals about appropriately prescribing supplemental fluorides. There is evidence of further need to minimize unnecessary ingestion of self-applied fluoride products, particularly dentifrices.

Resolution of early lesions of juvenile periodontitis with tetracycline therapy alone: long-term observations of 4 cases

Our previous studies have demonstrated that early-identified lesions of localized juvenile periodontitis (LJP) can be treated by the use of systemically administered tetracycline alone (1 gm/day for 6 weeks). This therapy results in arrest of disease progression, decreased pocket depths, gains in clinical attachment, and significant repair of alveolar defects. This paper reports on the long-term clinical and radiographic improvement in 4 subjects followed for 1 to 4 years after the completion of tetracycline therapy. Four patients (mean age 14 years) were examined 1 to 4 years following the completion of a single 6 week course of tetracycline. Mean pocket depth was reduced from the initial level of 7.1 mm to 3.6 mm. Mean attachment loss was reduced from 3.8 mm to 0.9 mm and angular bone defects had filled by an average of 72%. Pocket depths and attachment loss continued to decrease during the entire study period, while alveolar bone repair continued to increase. The findings support those of our previous investigation and confirm that: 1) early identified lesions of LJP can be effectively treated with 6 weeks of tetracycline therapy alone; 2) decreases in pocket depth, gains in clinical attachment, and repair of alveolar defects remain stable up to 4 years following antibiotic therapy; 3) clinical and radiographic improvement continues over time and may lead to complete resolution of some lesions; and 4) the reparative/regenerative potential of the periodontium in early onset disease in young individuals may exceed that observed in chronic adult periodontitis.

Associations of microbiological factors and plaque index with caries prevalence and water fluoridation status

Plaque indices, numbers of mutans streptococci, lactobacilli and total viable flora in plaque and saliva were assessed as part of a large-scale cross-sectional study designed to determine the factors that are associated with high caries activity in children. Subjects, 12 to 15 years old, residing in areas where the water supplies were either fluoridated (n = 140) or fluoride-deficient (n = 173) were studied. Mutans streptococci and lactobacilli numbers in saliva were positively correlated with plaque index. Plaque indices were significantly higher in the high-caries group than in the zero-caries group of the fluoride-deficient community. In the fluoridated community, there was no difference in the plaque index between the zero- or high-caries groups. In each community, pooled dental plaque and saliva harbored fewer mutans streptococci and lactobacilli in the zero-caries than the high-caries group. Greater numbers of mutans streptococci were found in the dental plaque and saliva of the zero-caries subjects in the fluoridated community than in the fluoride-deficient community, suggesting that a greater caries challenge can coexist with zero-caries status in the fluoridated community.

Monitoring of sedated pediatric dental patients

The results of this study showed that children sedated with 50 mg/kg chloral hydrate and 25 mg hydroxyzine in conjunction with 40 percent nitrous oxide and 60 percent oxygen may have respiratory difficulties which are not detected by the traditional monitoring of blood pressure, pulse, respiratory rate and skin color. The use of a pulse oximeter that noninvasively measures oxygen saturation of hemoglobin (SaO2) allowed earlier detection of respiratory distress, when correction was a relatively simple matter of readjusting head position. This combination of sedative agents was effective in managing two-thirds of the patients originally classified in a behavioral category of definitely negative. No children sedated with only 40 percent nitrous oxide and 60 percent oxygen exhibited respiratory problems, and over 80 percent of the patients classified in behavioral category of negative were managed effectively with this technique.

Tetracycline therapy in patients with early juvenile periodontitis

Tetracycline therapy, when used in conjunction with surgery or root planing, has been shown to be effective in controlling the progression of juvenile periodontitis. However, the ability of tetracycline alone to control the disease has not been assessed. The present study evaluated the effects of tetracycline therapy, with supragingival plaque control, on clinical attachment levels and radiographic bone height in patients with clinical and radiographic evidence of juvenile periodontitis. The four patients (mean age 15.2 +/- 0.3 yrs) each demonstrated loss of attachment of greater than or equal to 2 mm at one or more probing sites and had accompanying radiographic evidence of early localized bone loss. Following an initial clinical evaluation consisting of pocket depths, attachment levels and standardized radiographs, the patients received systemic tetracycline therapy (1 gm/day for three to six weeks) and oral hygiene instruction. At the completion of antibiotic therapy, patients received a supragingival professional prophylaxis every two weeks for three months, whereupon the initial evaluation was repeated. On comparing the initial and three-month clinical and radiographic data, there were significant decreases in clinical and radiographic measurements. For a total of 85 affected probing sites around 26 teeth, 79% decreased in pocket depth by greater than or equal to 2 mm (with no sites increasing in pocket depth) and 69% gained clinical attachment (with only one site losing attachment of 1 mm). Radiographic measurements revealed an increase in both the height and area of coronal alveolar bone. The findings indicated that six weeks of systemic tetracycline therapy combined with supragingival plaque control was effective in the initial control of early juvenile periodontitis.

Efficacy of using benzocaine for temporary relief of toothache

The purpose of this investigation was to determine the efficacy of benzocaine for temporary relief of toothache. The agent used is available at drug counters; it contains 7.5 percent benzocaine in propylene glycol and has the form of a gel. The study was double blind. The agent and a placebo were provided by the manufacturer in an equal number of randomly numbered but otherwise unlabeled tubes. Forty-nine patients (twenty-five males and twenty-four females) with throbbing toothache pain resulting from dental caries were included in the study. The mean age was 25.6 years for patients receiving the drug and 26.7 years for patients receiving the placebo. Of the twenty-four patients who received the active agent, twenty (83 percent) were relieved of pain. The average time for onset of relief was 3.7 minutes. In the placebo group, only four patients (16 percent) were relieved of pain. When the chi-square test is used, the difference is statistically significant at the 0.01 level. No adverse reaction to the agents used was observed.