Pediatric Odontogenic Infections.

Odontogenic infections are a broad group of head and neck conditions that arise from the teeth and surrounding periodontium. These largely preventable infections disproportionately affect members of ethnic and racial minorities and low-income/uninsured groups, and result in significant costs to our health care system. Left untreated, odontogenic infections can spread to deep spaces of the head and neck and can result in life-threatening complications. The mainstay of treatment includes timely treatment of the affected teeth. These infections are a global public health concern that could be diminished with improved access to routine dental care.

Dental and Dentoalveolar Injuries in the Pediatric Patient.

Dental and dentoalveolar injuries are common in the pediatric population. Management is predicated on the type of tooth injured (primary or permanent), extent of injury, the dental and behavioral age of the patient, and ability of the patient to tolerate treatment. Although many dental injuries occur in isolation, a systematic evaluation of the patient is mandatory to confirm the absence of basal bone fractures of the maxilla or mandible, traumatic brain injury, cervical spine injury, and/or facial soft tissue injury. Long-term follow-up is paramount to achieving a functional occlusion and optimal dental health following injury.

Do Standard Bibliometric Measures Correlate with Academic Rank of Full-Time Pediatric Dentistry Faculty Members?

The aim of this cross-sectional study was to assess the relationship between quantitative measures of research productivity and academic rank for full-time pediatric dentistry faculty members in accredited U.S. and Canadian residency programs. For each pediatric dentist in the study group, academic rank and bibliometric factors derived from publicly available databases were recorded. Academic ranks were lecturer/instructor, assistant professor, associate professor, and professor. Bibliometric factors were mean total number of publications, mean total number of citations, maximum number of citations for a single work, and h-index (a measure of the impact of publications, determined by total number of publications h that had at least h citations each). The study sample was comprised of 267 pediatric dentists: 4% were lecturers/instructors, 44% were assistant professors, 30% were associate professors, and 22% were professors. The mean number of publications for the sample was 15.4±27.8. The mean number of citations was 218.4±482.0. The mean h-index was 4.9±6.6. The h-index was strongly correlated with academic rank (r=0.60, p=0.001). For this sample, an h-index of ≥3 was identified as a threshold for promotion to associate professor, and an h-index of ≥6 was identified as a threshold for promotion to professor. The h-index was strongly correlated with the academic rank of these pediatric dental faculty members, suggesting that this index may be considered a measure for promotion, along with a faculty member's quality and quantity of research, teaching, service, and clinical activities.

Anticoagulation for Hypercoagulable Patients Associated with Complications after Large Cranioplasty Reconstruction.

BACKGROUND: Despite advancements in materials and techniques used for cranial reconstruction, complication rates following reconstructive cranioplasty remain significant. METHODS: In this study, the authors assessed the association of perioperative anticoagulation use and/or a hypercoagulable state with minor (i.e., not requiring surgical intervention) and major (i.e., surgical intervention required) complications after reconstructive cranioplasty for large skull defects. A retrospective cohort review of 108 consecutive cranioplasties performed between 2011 and 2014 was conducted. A multiple logistic regression analysis was performed to identify the adjusted association between the predictor variables and complications. RESULTS: Twenty-three primary (21.3 percent) and 85 secondary (78.7 percent) cranioplasties were performed on 94 patients with a median age of 50 years (interquartile range, 38 to 63 years). Median full-thickness calvarial defect size was 154 cm (interquartile range, 104 to 230 cm). Eleven minor (10.2 percent) and 18 major postoperative complications (16.7 percent) occurred in 26 cases (24.1 percent). Multiple logistic regression analysis revealed that coagulation status (i.e., perioperative use of anticoagulation therapy or hypercoagulable state) was statistically significant in predicting minor complications (OR, 7.8; 95 percent CI, 2.4 to 25.2; p = 0.001). Of note, the odds of a minor complication were an order of magnitude higher when both perioperative anticoagulation and a hypercoagulable state were present. CONCLUSION: To the authors' knowledge, this is the first study to document that the use of perioperative anticoagulant therapy for patients with thromboembolic conditions is a positive predictor of complications following cranioplasty reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Time Interval Reduction for Delayed Implant-Based Cranioplasty Reconstruction in the Setting of Previous Bone Flap Osteomyelitis.

BACKGROUND: Reinfections following implant-based cranioplasty, in the setting of previous bone flap osteomyelitis, are common and associated with significant morbidity. The timing of reconstruction following initial osteomyelitic bone flap removal remains controversial; most advocate for prolonged time intervals of approximately 6 to 12 months. Thus, the authors investigated their delayed cranioplasty outcomes following both early (between 90 and 179 days) and late (≥ 180 days) time intervals with custom craniofacial implants to determine whether timing affected outcomes and rates of reinfection. METHODS: An institutional review board-approved retrospective cohort review of 25 consecutive cranioplasties, from 2012 to 2014, was conducted. A nonparametric bivariate analysis compared variables and complications between the two different time interval groups, defined as early cranioplasty (between 90 and 179 days) and cranioplasty (≥ 180 days). RESULTS: No significant differences were found in primary and secondary outcomes in patients who underwent early versus late cranioplasty (p > 0.29). The overall reinfection rate was only 4 percent (one of 25), with the single reinfection occurring in the late group. Overall, the major complication rate was 8 percent (two of 25). Complete and subgroup analyses of specific complications yielded no significant differences between the early and late time intervals (p > 0.44). CONCLUSIONS: The results suggest that early cranioplasty is a viable treatment option for patients with previous bone flap osteomyelitis and subsequent removal. As such, a reduced time interval of 3 months--with equivalent outcomes and reinfection rates--represents a promising area for future study aiming to reduce the morbidity surrounding prolonged time intervals. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Is Canine Eruption Velocity Affected by the Presence of Allograft Within a Repaired Alveolar Cleft?

PURPOSE: To assess the rate of canine eruption in alveolar clefts repaired with cancellous autograft versus cancellous autograft mixed with allograft. MATERIALS AND METHODS: This was a retrospective cohort study of patients in mixed dentition who underwent primary repair of uni- or bilateral alveolar cleft defects. Patients were divided into 2 groups based on the method of bony reconstruction (group 1, iliac crest autograft; group 2, iliac crest autograft harvested through a minimal access approach and mixed 1:2 with demineralized bone allograft). Secondary predictor variables were demographic and anatomic factors potentially related to canine eruption. The outcome variable was the velocity of canine eruption, measured as the change in vertical distance from the incisal edge to the maxillary occlusal plane (millimeters per month). Descriptive, bivariate, and linear regression statistics were computed. RESULTS: The study sample included 57 alveolar cleft defects; 19 were repaired with autograft alone and 38 were repaired with autograft plus allograft. The sample's mean age was 9.9 ± 2.3 years at the time of repair. Thirty-one clefts (54.4%) were part of a bilateral deformity. Canine root formation was 50% complete at the time of surgery in most patients (59.6%). Mean duration of follow-up was 23.7 ± 13.2 months. Mean canine eruption velocity was 0.20 ± 0.18 mm per month and was not associated with the method of bony repair (P = .58). CONCLUSION: The use of allograft bone to augment bone graft volume results in similar rates of canine eruption compared with autograft bone alone.

Are panoramic radiographs predictive of temporomandibular joint synovitis in children with juvenile idiopathic arthritis?

PURPOSE: To identify specific panoramic radiographic findings associated with temporomandibular joint (TMJ) synovitis in children with juvenile idiopathic arthritis (JIA). MATERIALS AND METHODS: This was a retrospective study of children with JIA evaluated at Boston Children's Hospital. Patients were included if they had a confirmed diagnosis of JIA, a panoramic radiograph, and a contemporaneous TMJ magnetic resonance imaging (MRI) study with contrast. Medical records and imaging studies were reviewed to document demographic, panoramic (accentuated antegonial notch, short ramus and condyle unit [RCU] length, and abnormal condyle morphology: decreased condyle anteroposterior or superoinferior dimension) and MRI findings. The outcome variable was the presence or absence of TMJ synovitis on MRI. Descriptive and bivariate statistics and logistic regression models were used to identify associations (significant at P ≤ .05). RESULTS: Thirty patients (21 girls) with a mean age of 11.1 years (range, 5 to 16 yr) met the inclusion criteria. Of these, 15 patients had MRI scans positive for synovitis (bilateral in 18 joints in 9 patients and unilateral in 6 joints in 6 patients). The remaining 15 patients did not have evidence of synovitis on MRI. In the synovitis group, 18 of 24 joints (75%) showed abnormal panoramic findings (abnormal condyle morphology in 18 joints, accentuated antegonial notch in 9 joints, or short RCU length in 5 joints). In the nonsynovitis group, 15 of 36 joints (42%) showed abnormal panoramic findings (abnormal condyle morphology in 12 joints, accentuated antegonial notch in 6 joints, or short RCU length in 4 joints). Abnormal condyle morphology and accentuated antegonial notching on panoramic radiographs were found to be significantly correlated with synovitis (P = .0005 and .044, respectively). In a logistic regression model, abnormal condyle morphology was significantly associated with an increase in likelihood of TMJ synovitis versus those joints with normal condyle morphology (P = .007). Joints with abnormal condyle morphology and accentuated antegonial notching were 7.5 times as likely to have synovitis (P = .009) versus those joints without abnormal panoramic findings. CONCLUSION: Results of this preliminary study indicate that in this sample of children with JIA, the combination of abnormal condyle morphology and accentuated antegonial notching on a panoramic radiograph correlates with TMJ synovitis on MRI.

A systematic review of screw- versus cement-retained implant-supported fixed restorations.

PURPOSE: To systematically evaluate the survival and success of screw- versus cement-retained implant crowns. MATERIALS AND METHODS: The authors performed an electronic search of nine databases using identical MeSH phrases. Systematic evaluation and data extraction of the articles from 1966 through 2007 were completed by three reviewers and two clinical academicians. The major outcome variable was implant or crown loss, and the minor outcome variables were screw loosening, decementation, and porcelain fracture. Random effects Poisson models were used to analyze the failure and complication rates. RESULTS: The initial search produced 26,582 articles. Of these, 577 titles and subsequently 295 abstracts were available for evaluation, with 81 full texts meeting the criteria for review. Data were extracted from 23 level one and two research studies. Fleiss' kappa interevaluator agreement ranged from almost perfect to moderate. Major failures included 0.71 screw-retained and 0.87 cement-retained failures per 100 years. Minor failures included 3.66 screw loosenings, 2.54 decementations, and 0.46 porcelain fractures per 100 years. CONCLUSION: There is no significant difference between cement- and screw-retained restorations for major and minor outcomes with regard to implant survival or crown loss. This is important data, as clinicians use both methods of restoration, and neither is a form of inferior care.

The reporting of race and ethnicity information in the dental public health literature.

OBJECTIVES: To document how race and ethnicity are identified, categorized, and utilized in contemporary dental public health literature. METHODS: Two researchers independently performed a literature review of all articles in Community Dentistry and Oral Epidemiology and the Journal of Public Health Dentistry over a 5-year period (2004-2009). Articles pertaining to the study of US-based populations with any mention of race or ethnicity were included. The following data were abstracted from each article:( a) how each article broadly described race and/or ethnicity; (b) the terms used to specifically define the races and/or ethnicities captured; (c) the location of any mention of the concept of race and/or ethnicity; (d) the stated purpose for including race and/or ethnicity concepts; (e) the stated analytic use of race and/or ethnicity concepts; and (f) the stated method used to assess race and/or ethnicity concepts. RESULTS: Overall, race and/or ethnicity concepts were most commonly referred to within the text of the results section. Fifty percent of articles did not state their purpose for including race and/or ethnicity concepts within their studies, while 34.3 percent omitted stating their analytic use of these concepts. When assessing these concepts, 41.4 percent relied upon subject self-report. CONCLUSION: These data showed that there was inconsistent documentation of how race and ethnicity was measured. While race and ethnicity are important measures for public health studies and are frequently reported in dental public health research, there is no clear system for classifying these measures.

Physical findings associated with active temporomandibular joint inflammation in children with juvenile idiopathic arthritis.

PURPOSE: To identify the physical findings associated with active temporomandibular joint (TMJ) inflammation (ie, synovitis) in children with juvenile idiopathic arthritis (JIA). PATIENTS AND METHODS: This was a retrospective study of children with JIA evaluated at Boston Children's Hospital. The patients were included if they had a confirmed diagnosis of JIA and had undergone a TMJ magnetic resonance imaging (MRI) study with contrast. Medical records and imaging studies were reviewed to document the demographic, physical (ie, facial asymmetry, joint noises, maximal incisal opening, deviation on opening, occlusal cant), and MRI findings. The outcome variable was TMJ synovitis on the MRI study. Descriptive and bivariate statistics were computed. Multiple regression models were used to identify associations (P ≤ .05, significance). RESULTS: A total of 51 patients with JIA were evaluated during the study period. Of these, 43 patients (33 girls) with a mean age of 11.4 years met the inclusion criteria. MRI demonstrated TMJ synovitis in 27 patients. The age-adjusted limited maximal incisal opening (MIO) and deviation on opening were the only physical findings significantly associated with synovitis on MRI (P = .003 and P = .043, respectively). Using these parameters as predictors of synovitis, a limited MIO and deviation on opening had a high specificity (86% and 94%, respectively). Patients with a limited MIO were 6.7 times more likely to have synovitis than those with a normal MIO. All patients with a limited MIO and deviation on opening had TMJ synovitis on the MRI scan. CONCLUSIONS: The results of this study indicate that, in children with JIA, limited MIO and deviation on opening can be used to predict the presence of TMJ synovitis. Documentation of these parameters should be an essential part of the clinical examination and longitudinal follow-up of children with JIA.

Differentiating arthritic from myofascial pain in children with juvenile idiopathic arthritis: preliminary report.

PURPOSE: To differentiate between temporomandibular joint (TMJ) inflammation and myofascial pain (MPD) in children with juvenile idiopathic arthritis (JIA). PATIENTS AND METHODS: We performed a retrospective study of children with JIA evaluated at Boston Children's Hospital, Boston, Massachusetts. Patients, aged 16 years or younger at the time of diagnosis, were included if they had confirmed JIA with jaw signs or symptoms. Medical records and imaging studies were reviewed to document demographic, clinical, and radiographic findings. Patients with clinical evidence (joint pain/tenderness, asymmetry, limited motion) and radiographic evidence (condylar asymmetry, flattening, accentuated antegonial notch) of TMJ inflammation but without muscle pain were diagnosed with arthritis. Those with only muscle tenderness and/or limited jaw motion were diagnosed with MPD. Patients with TMJ inflammation and muscle pain/tenderness were considered to have co-existing arthritis and MPD. Outcome variables were the presence of TMJ arthritis and/or MPD. Descriptive statistics were computed. RESULTS: There were 61 patients (44 girls) with a mean age of 12.7 years (range, 3 to 16 years) who met the inclusion criteria. The most common clinical findings were limited mouth opening (n = 24), malocclusion/asymmetry (n = 23), and/or tenderness to palpation (n = 18). Twenty-one patients had multiple signs and symptoms. Panoramic radiographs showed condylar abnormalities in 32 patients. Overall, 21 patients (34.4%) were diagnosed with active TMJ arthritis, 21 (34.4%) with MPD, and 11 (18%) with both arthritis and MPD. Of the patients, 8 (13.1%) were in remission. CONCLUSIONS: The results of this study indicate that in patients with JIA and jaw signs/symptoms, there is an overlap in diagnoses between arthritis and MPD. This has considerable implications for patient management.

Does a case completion curriculum influence dental students' clinical productivity?

The purpose of this study was to evaluate the effects of a new clinical curriculum on dental student productivity as measured by number of procedures performed in the student teaching practice. Harvard School of Dental Medicine adopted a new clinical education model for the predoctoral program in summer 2009 based upon a Case Completion Curriculum (CCC) rather than a discipline-based numeric threshold system. The two study groups (threshold group and case completion group) consisted of students who graduated in 2009 and 2010. Clinical performance was assessed by clinical productivity across five major discipline areas: periodontics, operative dentistry, removable prosthodontics, fixed prosthodontics, and endodontics. The relationships between the two study groups with regard to number of procedures performed by category revealed that the case completion group performed a significantly higher number of operative and removable prosthodontic procedures, but fewer periodontal and endodontic procedures (p≤0.03). No statistically significant difference in number of procedures was observed with fixed prosthodontic procedures between the two groups. Clinical productivity as a result of redesigning the clinical component of the curriculum varied in selected disciplines. The CCC, in which the comprehensive management of the patient was the priority, contributed to achieving a patient-based comprehensive care practice.