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.

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 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.

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 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.

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.

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.

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.

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.

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.

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.