November 10, 2017
AAPD/AAP report discusses oral and dental aspects of child abuse and neglect
Pediatric dentists and oral and maxillofacial surgeons, whose advanced education programs include a mandated child abuse curriculum, can provide valuable information and assistance to other health care providers about oral and dental aspects of child abuse and neglect. The finding is part of a report published concurrently in the July-August issue of Pediatric Dentistry and in the August issue of Pediatrics.
Researchers compiled the report to review the oral and dental aspects of physical and sexual abuse and dental neglect in children, and the role of pediatric health care providers and dental care providers in evaluating such conditions. The report addresses the evaluation of bite marks, perioral and intraoral injuries, infections, and diseases that may raise suspicions of child abuse or neglect.
Oral injuries may be inflicted with instruments such as eating utensils or a bottle during forced feedings, hands, fingers, scalding liquids, or caustic substances. Trauma to the teeth may result in pulpal necrosis, leaving the teeth gray and discolored. Unintentional or accidental injuries to the mouth can be distinguished from abuse by judging whether the history (including the timing and mechanism of the injury) is consistent with the characteristics of the injury and the child’s developmental capabilities. Multiple injuries, injuries in different stages of healing, or a discrepant history should arouse suspicion for abuse.
Accuracy in diagnosing sexually transmitted infections of the oral cavity is increased if evidence is collected within 24 hours of exposure in prepubertal children and within 3 days in adolescents. Human papillomavirus infections may be transmitted sexually through oral-genital contact, vertically from mother to infant during birth, or horizontally through nonsexual contact from a child or caregiver’s hand to the genitals or mouth.
Bite marks should be suspected when ecchymoses (contusions), abrasions, or lacerations are found in an elliptical, horseshoe-shaped, or ovoid pattern. Bite marks may have a central area of ecchymoses caused by the following 2 possible phenomena: positive pressure from the closing of the teeth with disruption of small vessels or negative pressure caused by suction and tongue thrusting. Bites produced by dogs and other carnivorous animals tend to tear flesh, whereas human bites compress flesh and can cause abrasions, ecchymoses, and lacerations but rarely avulsions of tissue. An intercanine distance (that is, the linear distance between the central point of the canine tooth tips) measuring more than 3 centimeters may indicate an adult human bite.
Children who reported physical abuse, intimate partner violence, forced sex, and bullying were found to also report having poor oral health. In the United States, more than one-half (54.3%) of women and adolescents reported dental problems, most commonly tooth loss (42.9%). Child trafficking victims have twice the risk of developing dental problems because they often experience inadequate nutrition leading to retarded growth and poorly formed teeth, as well as caries, infections, and tooth loss.
Caregivers with adequate knowledge and willful failure to seek care must be differentiated from caregivers without knowledge or awareness of their child’s need for dental care when determining the need to report such cases to child protective services.
Read the complete articles here and here.
Consulting Editor: Paul S. Casamassimo, DDS, MS
Professor Emeritus, The Ohio State University College of Dentistry
and Nationwide Children's Hospital, Columbus, OH
Consulting Editor: Arthur J. Nowak, DMD
Professor Emeritus, University of Iowa College of Dentistry
Prescription of panoramic radiographs in children
General dentists prescribed panoramic radiographs (PR) more often during routine care at earlier patient ages than recommended in the American Dental Association and American Academy of Pediatric Dentistry guidelines. Pediatric dentists (PDs) prescribed a higher percentage of PRs around the typical age of eruption of the permanent first molar, which fits within the guidelines. The findings are from a study published in the July-August issue of Pediatric Dentistry.
The purpose of the study was to determine if clinicians adhere to American Dental Association and American Academy of Pediatric Dentistry guidelines when prescribing panoramic images for patients 18 years and younger, and to contrast prescribing practices between general practitioners (GPs) and PDs.
Researchers conducted a retrospective analysis of insurance claims that included current dental terminology (CDT) codes for panoramic radiographs (PRs) for 448,880 procedures for 2 cities between 2008 and 2015.
Procedures were associated with a PR code, divided by age groups, and placed into 4 code groups: routine examinations, orthodontic procedures, procedures involving third molars, and procedures for acute problems. For each group, χ2 tests were conducted to ascertain the likelihood of a PR being associated with this procedure group between GPs and PDs for each age group.
The data included 81,699 pediatric patients 18 years and younger who had private dental insurance and were seen in Cincinnati, OH, or Dallas, TX, between March 2008 and August 2015 by 2,077 GPs and 103 PDs. Among all of the GP or PD procedures were 11,993 PRs, 119,068 routine examination procedures, 13,819 orthodontic procedures (378 associated with a PR), 798 third-molar procedures, and 16,636 procedures for acute problems (1,670 associated with a PR).
GPs obtained more PRs during routine examinations for patients younger than 6 years, 10-year-old patients, and patients who were at least 12 years old. The highest percentages were in 7-years-olds for PDs and 17-year-old for GPs. The overall percentage of patients receiving a PR during routine examinations was 7.54% overall, with 7.64% for GPs and 7.43% for PDs. GPs most frequently performed procedures 3 days before and up to 15 days after the first PR. The distribution was more evenly spread among ages for PDs. PRs associated with orthodontic procedures peaked in 6-years-olds for GPs and 8-year-olds for PDs.
PRs associated with third molars were higher for every age group for GPs. PRs associated with codes for acute clinical problems were higher for GPs for all age groups.
The largest discrepancy between GPs and PDs for PRs during routine examinations was for patients younger than 6 years, 7-year-old patients, 8-year-old patients, and 15-year-old patients. The ages most similar between GPs and PDs were 9- to 11-year-old and 16- to 18-year-olds. The mean number of days between a PR and another procedure was 10.59 for GPs and 8.39 for PDs. The mean age for a PR was 12.41 years for GPs and 10.11 years for PDs. The mean number of days between multiple PRs was 255 for GPs and 304 for PDs.
Read the complete article here.
Save time with the NEW JADA+ Clinical Scans
The Journal of the American Dental Association (JADA) is making it easier for members to access the latest scientific studies. The new JADA+ Clinical Scans provide a brief overview of selected articles and offer a scientific- and evidence-based assessment of the published research, providing critical information that helps dental professionals integrate their patients’ needs and preferences into treatment decisions. Read them at JADA.ADA.org/ClinicalScans. New clinical scans are added frequently, so check back often.
Healing complications risk in primary teeth with intrusive luxation
More than 80% of intruded primary teeth re-erupted spontaneously. Nearly one-third of teeth had complications such as pulp infection/periapical inflammation or ankylosis, which could affect the development of permanent incisors. Children younger than 2 years appeared to have the lowest risk of developing pulpal necrosis and infection and experiencing premature tooth loss. Most complications were diagnosed within the first year after the injury. The findings are from a study published online September 18 in Dental Traumatology.
The researchers conducted the study to measure the risk of pulpal necrosis (PN), pulp canal obliteration (PCO), infection-related resorption (IRR), ankylosis-related resorption (ARR), repair-related resorption, and premature tooth loss (PTL) in primary teeth with intrusive luxation, as well as to identify risk factors for PN and PTL in primary teeth with intrusive luxation.
The study included 149 patients (61 girls and 88 boys) with 194 intruded primary incisors. Standard follow-up included clinical and radiographic examination 4 weeks, 8 weeks, 6 months, and 1 year after the trauma and again when the patient was 6 years old. The researchers did not provide treatment or perform electric pulp testing.
The Kaplan-Meier and Aalen-Johansen estimators were used along with Cox regression analysis. The level of significance was 5%.
Most teeth (83.7%) spontaneously re-erupted within the first year. A total of 74 teeth developed PCO. PCO occurred in all age groups, but Cox regression analysis showed a significantly higher risk among 3-year-olds. The degree of intrusion and the presence of a concomitant crown fracture did not affect the risk of developing PCO. One-half of the cases of PCO were diagnosed at the 1-year follow-up visit. Yellow discoloration was seen in 41 teeth (21%), and gray discoloration was seen in 27 teeth (14%).
In all, 45 teeth showed signs of pulp necrosis and infection. Among these, 16 teeth also showed signs of IRR. Multivariate analysis showed that the risk of developing PN was much higher among 2-year-olds, whereas the degree of intrusion and the presence of a concomitant crown fracture did not affect the risk of developing PN.
A total of 16 teeth developed IRR. Five teeth (31.3%) received a diagnosis after 2 months and 12 teeth (75.0%) within the first year. A total of 7 teeth received a diagnosis of ARR. Six teeth (85.7%) received a diagnosis within the first year. A total of 6 teeth received a diagnosis of repair-related resorption.
Ten teeth were extracted at the day of the injury owing to displacement of the primary tooth into the permanent tooth germ. Among the 194 teeth included in the study, 72 teeth (37%) were lost prematurely during follow-up. The estimated risk of experiencing PTL after 3 years was 39.4% (95% confidence interval, 31.2 to 47.5). Eight teeth (11.1%) were extracted within the first week after the injury. At the 2-month follow-up visit, 39 teeth had been lost (54.1%), and at 1-year follow-up, 69 teeth had been lost (95.8%). Hence, most cases of PTL occurred within the first year after the injury. The reasons for PTL were extraction due to PN or IRR (45 teeth), extraction due to ARR (7 teeth) and accelerated physiological resorption (3 teeth). The reason for PTL For the remaining 17 teeth was unknown.
At the 1-year follow-up visit, 125 teeth remained in place and the position of these teeth was evaluated. A total of 104 teeth (83.7%) had re-erupted spontaneously to their original positions. The remaining 21 teeth (16.3%) were still intruded.
Read the complete article here.
Evaluating effectiveness of esthetic preformed pediatric crowns
Owing to the small number of randomized clinical trials (RCT) and risk of bias, changing American Academy of Pediatric Dentistry recommendations for use of stainless steel crowns for primary teeth with extensive caries, due to their greater longevity than other intracoronal restorations is not advised for posterior teeth. Zircon crowns appeared to be the best crown restoration for incisors at 6 months, but they should be evaluated over periods of at least 1 year in primary anterior and posterior teeth. These findings are from a study published online June 7 in International Journal of Paediatric Dentistry.
The objective of this review was to evaluate the clinical effectiveness of all types of esthetic preformed crowns for restoring primary teeth compared with that of conventional filling materials or other types of crowns.
Eligible studies included published randomized clinical trials (RCTs) about esthetic preformed crowns compared with conventional filling materials, stainless steel crowns (SSCs), or different esthetic preformed crowns for restoring primary teeth. Researchers searched databases of PubMed via MEDLINE and the Cochrane Central Register of Controlled Trials. Two review authors independently assessed the risk of bias in the included articles and extracted data.
Researchers chose 7 relevant articles from a search that yielded 555 articles that were potentially eligible. One study covered primary incisors, and 6 covered primary molars. The overall risk of bias was high for all the studies. SSCs cannot be replaced by esthetic preformed crowns, such as the open-faced SSCs and preveneered SSCs, for restoring badly carious primary molars. Zircon crowns were assessed in only primary incisors and compared with preveneered SSCs and resin composite strip crowns.
Only 1 parallel group RCT was carried out to compare resin composite strip crowns, preveneered SSCs, and zircon crowns. No pulpotomy was performed before crown placement. The primary outcome was fracture (partial or complete), and the secondary outcomes were both gingival index and tooth wear on opposing teeth.
“None of the included trials had registered a protocol,” the authors noted. “We could not compare the reports of published results with the registered trial record, nor could we assess whether outcomes had been omitted or changed; this represents the real risk of bias for selective outcome reporting.”
Read the complete article here.
ADA dental sealants brochure is vital tool to fight decay
Dental Sealants: Protecting Teeth, Preventing Decay gives your young patients added protection against tooth decay by helping parents understand why the sealants are a vital part of your decay-fighting strategy. With this revised ADA brochure, they’ll be even more invested in getting it applied to their children’s teeth.
- Tips for preventing tooth decay.
- Evidence that sealants are safe and healthy.
- A sealant analogy that parents can share with their kids to help them understand the importance of sealants.
- Photos of a tooth surface before and after sealant is applied.
The 6-panel brochure is available in packs of 50 from the ADA Catalog. A sample can be viewed here. To order, call 1-800-947-4746 or go to ADAcatalog.org. Dental Sealants is also available in Spanish. The title is available personalized as well. Readers who use the code 17411E before December 1 can save 15 percent on all ADA Catalog products.
Brush up on pediatric dentistry
Do you treat children in your office? Are you in need of pedo CE? We have just the thing for you! The American Academy of Pediatric Dentistry has a jam-packed Spring 2018 continuing education lineup. The Comprehensive Review, Sedation and Simulation courses are all available for members and nonmembers alike. If you’re looking for a refresher course or need to hone your emergency management skills, we’ve got you covered. Register today and you’ll still have the chance to get the early bird fees.
Dental Practice Success: Your guide to a healthy practice
Dental Practice Success is designed with our member dental professionals in mind. This e-Pub features must-read articles that offer the member dentist resources and information to help them succeed as dental practitioners and small business owners. Dental Practice Success is emailed quarterly.
JADA+ Specialty Scans and JADA+ Scans
JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.
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