Salivary glucosyltransferase B as a possible marker for caries activity.

Bacteria-derived glucosyltransferases (Gtf) (EC 2.4.1.5), through synthesizing glucan polymers from sucrose and starch hydrolysates, play an essential role in the etiology and pathogenesis of caries. We attempted to correlate the levels of Gtf in whole saliva with the prevalence of carious lesions in young children. We examined saliva from children who were either free of overt carious lesions, or had severe early childhood caries (mean dmfs = 18.72 +/- 9.0 SD), for Gtf by direct enzyme assay. The levels of GtfB, GtfC and GtfD from Streptococcus mutans in the saliva using monoclonal/specific antibodies in an enzyme-linked immunosorbent assay were determined. Multiple logistic regression analyses with model selection showed that GtfB levels correlated with dmfs values of the subjects (p = 0.006). There was no correlation between total Gtf activity as measured by direct enzyme assay and dmfs values. There was a strong correlation between mutans streptococci populations in saliva and caries activity. Collectively, these data show that GtfB levels in saliva correlate strongly with presence of clinical caries and with number of carious lesions in young children. It is also possible to measure different Gtfs, separately, in whole saliva. These observations may have important clinical implications, may lead to development of a chair side caries activity test and support the importance of GtfB in the pathogenesis of dental caries.

Clinical outcomes for early childhood caries: influence of aggressive dental surgery.

PURPOSE: The objective of this study was to assess the relationship between the number of stainless steel crowns (SSCs) placed, number of surfaces at risk (SAR) post dental surgery, and the risk for relapse in patients treated for Early Childhood Caries (ECC). METHODS: The study population consisted of 57 children treated for ECC under general anesthesia, ranging in age from 2.3 to 7.3 years old at the time of entry. Dental surgery utilized an aggressive approach: teeth that had necrotic pulps or were nonrestorable were extracted; decayed primary mandibular incisors that could not be treated by stripping were extracted; primary maxillary incisors with 3 or more carious surfaces were extracted; single-surface lesions of primary molars that did not compromise cusp integrity were restored with intracoronal amalgam restorations; primary maxillary, incisors and canines with smooth-surface lesions affecting 2 or less surfaces were treated with intracoronal composites; primary molars and canines requiring vital pulp therapy were restored with SSCs; primary molars with caries lesions affecting 2 or more surfaces (including smooth-surface, white-spot lesions) were restored with SSCs; primary canines with caries affecting 3 or more surfaces were restored with stainless steel crowns; topical fluoride was applied after all restorative therapy was completed. The cohort was examined for new caries lesions 6 months post dental surgery. Relapse was defined as the presence of new smooth-surface caries lesions as defined by Radike. Comparisons between relapse (R) and nonrelapse (NR) groups, with respect to the number of SSCs placed and the number of SAR, were performed using t tests and Wilcoxon tests. A 0.05 level of significance was employed in all statistical tests. RESULTS: Twenty-one of the 57 (37%) patients relapsed. No statistically significant difference for the number of SSCs placed or SAR existed between the R group (SSCs: mean = 4.57, median = 4 +/- 2.18; SAR: mean = 39.76, median = 40 +/- 13.62) and NR group (SSCs: mean=5.44, median = 5.5 +/- 2.62; SAR: mean = 39.98, median = 39.5 +/- 15.19). CONCLUSIONS: The risk for relapse in children treated for ECC is not associated with the number of SSCs placed or SAR; aggressive dental surgery for ECC does not result in acceptable clinical outcomes.

Clinical outcomes for Early Childhood Caries (ECC): the influence of salivary mutans streptococci levels.

AIM: To assess the relationship between clinical outcomes for children treated for Early Childhood Caries (ECC) and salivary mutans streptococci (MS) levels. STUDY DESIGN AND METHODS: The study cohort consisted of 79 children (42 males, 37 females) treated for ECC, aged from 2.3 to 7.3 years at time of entry. Whole non-stimulated saliva samples were obtained from each subject prior to dental surgery and at 6 mths post dental surgery, by saturating a cotton swab in the saliva pooled in the floor of the mouth. Samples were placed into PBS on ice and processed within 2 hours. Samples were sonicated, serially diluted and plated onto MSB and SBA agar plates, then incubated 48 hours anaerobically; SBA plates were incubated an additional 24 hours aerobically. The MS level in each sample was expressed as a percentage of the total cultivable flora. The cohort was evaluated for new caries lesions at 6 months post dental surgery. Relapse was defined as the presence of new smooth surface caries lesions. STATISTICS: Comparisons between Relapse (R) and Non-Relapse (NR) groups with respect to mutans streptococci levels were performed using Wilcoxon tests. Within group comparisons were performed using Wilcoxon signed-rank tests. RESULTS: 57 children (72%) returned for the 6 months examination and 21 of these subjects (37%) relapsed. No statistically significant difference in median salivary MS levels existed between the R (0.20%) and NR (0.033%) groups at baseline (p=0.647) or at 6 months post dental surgery (R=0.03%; NR=0.01%; p=0.273). A statistically significant difference between baseline and 6 months post dental surgery was noted in the median salivary MS level within the R group (p=0.0007) and within the NR group (P<0.0001). CONCLUSIONS: The relapse rate (37%) was high and rapid for children treated for ECC. Dental surgery resulted in a statistically significant reduction in salivary MS reservoirs for children treated for ECC. However, this did not translate into acceptable clinical outcomes.

Clinical outcomes for Early Childhood Caries (ECC): the influence of health locus of control.

AIM: To assess the relationship between clinical outcomes for children treated for ECC and health locus of control. STUDY DESIGN AND METHODS: The study cohort consisted of 79 children (42 males, 37 females) treated for ECC; age range was 2.3-7.3 years (mean 4.2 years) at the time of entry into the study. A questionnaire [developed by DeVellis et al., 1993] was administered to each child's parent(s) on the day of dental surgery. This questionnaire examined the expectation that healthcare outcomes in children are influenced by one of the following loci of control: Professional, Parent, Child, Media, Fate and Divine. The cohort was evaluated for new caries lesions at 6 months post dental surgery. Relapse was defined as the presence of new smooth surface caries lesions. STATISTICS: For each locus, the scores for the Relapse versus Non-relapse groups (returning patients) and the scores for the returning versus non-returning patients were compared using t-tests. RESULTS: 57 children (72%) returned for follow-up and 21 of these 57 (37%) relapsed. No statistically significant difference for Relapse versus Non-relapse groups was indicated with respect to the scores for any locus parameter (p values ranged from 0.35 to 0.95). Returning parents (N=57) versus non- returning parents (N=22) exhibited statistically significant differences with respect to the Parent, Divine and Fate loci. Returning parents exhibited higher scores on the Parent locus (p=0.0392) and lower scores on the Fate (p=0.0024) and Divine (p=0.0031) loci. CONCLUSION: 1). The relapse rate (37%) was high and rapid for children treated for ECC; 2). no meaningful difference existed between the Relapse versus Non-relapse groups with respect to each health locus of control parameter; 3). parents who returned for follow-up care appeared to have an internal health locus of control while those who did not return had an external locus.

Delayed tooth eruption: association with severity of HIV infection.

PURPOSE: HIV status is monitored by expression of clinical symptoms as well as CD4 lymphocyte counts. The purpose of this study is to assess the relationship between delayed dental eruption (DDE) and the progression of pediatric HIV infection to AIDS. METHODS: A population of 70 perinatally HIV-infected children, aged 5 months to 13 years at their time of entry into the study, received dental examinations. Regression analysis between dental age and chronological age was performed. Subject CDC classification, adjusted for age, was used to determine an association between eruptive delay and severity of disease progression. RESULTS: Data revealed no significant difference in timing of eruption based on severity of CD4 depletion alone (P = 0.09). However, clinical symptom status was strongly associated with DDE (P = 0.003). The relationship between symptoms and DDE persisted after controlling for CD4 depletion. CONCLUSIONS: Our study indicates that there is a correlation between the progression from HIV infection to Pediatric AIDS and DDE and that this delay is most closely linked to severity of symptoms and not CD4 depletion.

Mutans streptococci prevalence in Puerto Rican babies with cariogenic feeding behaviors.

PURPOSE: Previous studies have demonstrated that babies are at higher risk for mutans streptococci (ms) colonization if their mothers have dense salivary ms reservoirs relative to babies who have mothers with negligible salivary reservoirs. This communication provides data that identifies another potential risk factor (use of a nursing bottle at bedtime and/or naptime that contains a substrate other than water) for baby infection by ms. METHODS: The study population consisted of 60 babies (28 males/32 females; mean age 15 mos; age range 12-18 mos) who were all healthy, caries free, and slept with a nursing bottle that contained a substrate other than water (NB+). Pooled maxillary incisor plaque and saliva samples were obtained and immediately placed in Reduced Transparent Fluid (RTF); they were serially diluted and plated onto Mitis Salivarius Agar plus Bacitracin (MSB) and blood agar plates within 4 hours of collection; the plates were incubated in an anaerobic environment for 48 h at 37 C and then placed for 24 h under aerobiosis prior to examination; representative ms colonies were isolated and subjected to mannitol and sorbitol fermentation tests for taxonomic verification. Plates with colony counts between 20 and 300 were utilized to determine the % of ms in each sample. RESULTS: Fifty one of the 60(85%) babies harbored ms in at least 1 of the 2 samples. The 95% confidence interval for the proportion of subjects with detectable levels of ms was 73%-93%. Fisher's exact test showed that babies 16-18 mos age were more likely to have detectable levels of ms than babies 12-15 mos age (p = 0.01). Levels of ms in plaque and saliva were as follows: < 0.1% (plaque 27/51, mean age 15 mos, sd 1.77; saliva 28/51, mean age 15 mos, sd 1.76); 0.1%-1.0% (plaque 4/51, mean age 14 mos, sd 1.5; saliva 6/51, mean age 15 mos, sd 1.46); > 1.0% (plaque 14/51, mean age 16 mos, sd 2.1; saliva 11/51, mean age 16 mos, sd 1.91). The density of infection did not vary by age for plaque (P = 0.32) or saliva (P = 0.64). CONCLUSION: These findings support the concept that NB+ is a strong indicator for ms infection in Puerto Rican babies; that prevalence of infection increases with age; and that density of infection does not vary with age in this population.

Anaphylactoid reaction to muromonab-CD3 in a pediatric renal transplant recipient.

Muromonab-CD3 (OKT3), a murine IgG2a antibody directed against the T3 (CD3) complex on mature lymphocytes, triggers adverse immune reactions. Anaphylactic reactions have occurred in patients exposed to OKT3 and are mediated by anti-OKT3 IgE antibodies. The reactions are not antibody mediated and can occur within seconds of administration of a mast cell secretogogue. A renal transplant recipient became hypotensive and hypoxic immediately after receiving her first dose of OKT3 and required advanced life support. Serum antibody tests were negative for anti-OKT3 IgG, IgE, and antimouse protein antibodies. To our knowledge, this is the first published report of a patient with an anaphylactoid reaction to the initial infusion of OKT3.

Upper airway obstruction during midazolam/nitrous oxide sedation in children with enlarged tonsils.

PURPOSE: The purpose of this nonrandomized, case-control study was to examine the incidence and severity of upper airway obstruction (UAO) in children with enlarged tonsils during inhalation of nitrous oxide (N2O). METHODS: Following premedication with oral midazolam, 0.5 mg/kg, measurements were collected during a 3-minute control period followed by 3 minutes of breathing 50% N2O in oxygen. An unblinded anesthesiologist held a facemask over the child's mouth and nose without supporting the head or neck, or attempting to maintain airway patency. Every 20 seconds, the degree of airway obstruction was graded as none, partial, or complete. Twenty-five children presenting for tonsillectomy and 25 controls without enlarged tonsils participated. RESULTS: During 50% N2O inhalation, 14 children (56%) in the tonsillectomy group, and four children (16%) in the control group demonstrated partial UAO. One child in the tonsillectomy group with partial UAO developed hypoxemia (SpO2 72%). One child in the tonsil group developed complete UAO during inhalation of 50% N2O. CONCLUSION: Children who receive sedation with oral midazolam and 50% N2O inhalation may exhibit significant UAO, especially in the presence of enlarged tonsils. Presedation physical exams should evaluate the presence of tonsil size during examination of the mouth and airway.

Chloral hydrate sedation: the additive sedative and respiratory depressant effects of nitrous oxide.

UNLABELLED: The combination of chloral hydrate and nitrous oxide (N2O) is often used for sedation in pediatric dentistry. The purpose of this study was to determine the extent to which N2O increases the level of sedation and respiratory depression in children sedated with chloral hydrate. Thirty-two children, 1-9 yr, received chloral hydrate, 70 mg/kg (maximum 1.5 g), and then received N2O (30% and 50%). Hypoventilation (maximal PETCO2 > 45 mm Hg) occurred in 23 (77%) children during administration of chloral hydrate alone, in 29 (94%) breathing 30% N2O (P = 0.08 versus control), and in 29 (97%) breathing 50% N2O (P = 0.05 versus control). Mean PETCO2 was increased during 30% (P = 0.007) and 50% (P = 0.02) N2O administration. Using chloral hydrate alone, 8 (25%) children were not sedated, 10 (31%) were consciously sedated, and 14 (44%) were deeply sedated. Using 30% N2O, 2 children (6%) were not sedated, 0 were consciously sedated, and 29 (94%) were deeply sedated (P < 0.0001). Using 50% N2O, 1 child (3%) was not sedated, 0 were consciously sedated, 27 (94%) were deeply sedated, and 1 (3%) had no response to a painful stimulus (P < 0.0001). We conclude that the addition of 30% or 50% N2O to chloral hydrate often causes decreases in ventilation and usually results in deep, not conscious, sedation in children. IMPLICATIONS: Pediatric sedation in the dental office often consists of nitrous oxide (N2O) after chloral hydrate premedication. We found that the addition of 30% or 50% N2O to chloral hydrate often causes decreases in ventilation and usually results in deep, not conscious, sedation in children.

Breathing patterns and levels of consciousness in children during administration of nitrous oxide after oral midazolam premedication.

PURPOSE: The combination of midazolam and nitrous oxide is commonly used to achieve sedation and analgesia during pediatric oral procedures, yet there are few, if any, data that illustrate the ventilatory effects of N2O in children, especially when used in combination with additional central nervous system (CNS) depressants. It was hypothesized that the addition of N2O inhalation to oral midazolam premedication would enhance the sedative effects of the midazolam and add analgesia without causing significant respiratory depression. The purpose of this study was to test this hypothesis. MATERIALS AND METHODS: Thirty-four healthy children about to undergo restorative dental treatment under general anesthesia were premedicated with oral midazolam, 0.7 mg/kg, and were then exposed to 40% N2O for 15 minutes after a 5-minute control period. The effect of adding N2O on SpO2, respiratory rate, PETCO2, VT, and VT/TI was examined and the levels of consciousness (conscious vs deep sedation) before and during N2O inhalation were determined. RESULTS: During the course of the study, no child developed hypoxemia (SpO2 < 92%) nor clinically significant upper airway obstruction. Four children who did not develop hypoventilation (defined as PETCO2 > 45 mm Hg) during the control period did so after initiation of N2O. Overall, there were no significant differences in SpO2, PETCO2, VT, or VT/TI between the control and study periods. However, respiratory rates were significantly higher in the first 10 minutes of N2O inhalation when compared with the control period. Before starting N2O administration, 14 children were not clinically sedated, 19 children met the criteria for conscious sedation, and one child met the criteria for deep sedation. At the end of 15 minutes of N2O inhalation, 12 children were not clinically sedated, 17 children met the definition of conscious sedation, three were deeply sedated, and one child had no response to IV insertion, implying a state of general anesthesia. There were no differences in sedation scores between the control and study periods (P = .6). Overall, seven children had an increase in their sedation score while breathing N2O, four had a decrease in their sedation score, and 22 had no change. CONCLUSIONS: The addition of 40% N2O to oral midazolam, 0.7 mg/kg, did not result in clinically meaningful respiratory depression nor upper airway obstruction, but did, in some children, cause an increase in the level of sedation beyond simple conscious sedation.

Clinical outcomes for nursing caries treated using general anesthesia.

This study did follow-up examinations of 84 Medicaid-eligible children with nursing caries after they received treatment for nursing caries utilizing general anesthesia. Results at six months suggest that parents are unresponsive to follow-up care and over half of the children seen had new smooth surface caries lesions. While results are preliminary, they suggest that major changes are needed in the tertiary care of children with nursing caries.

Levels of consciousness and ventilatory parameters in young children during sedation with oral midazolam and nitrous oxide.

OBJECTIVE: To determine the ventilatory effects and levels of consciousness achieved during sedation with the combination of oral midazolam and inhaled nitrous oxide. DESIGN: Case series. SETTING: Surgical suite. PATIENTS: Twenty-two consecutive children, aged 1 to 3 years, were seen for elective, ambulatory surgery. INTERVENTIONS: Patients were premedicated with oral midazolam hydrochloride, 0.5 mg/kg, and then breathed 4 concentrations of nitrous oxide (N2O) in oxygen (15%, 30%, 45%, and 60%) for 4 minutes at each concentration prior to induction of general anesthesia. MAIN OUTCOME MEASURES: Levels of consciousness (conscious vs deep sedation) and ventilatory parameters: respiratory rate, end-tidal carbon dioxide tension (PETCO2), and oxyhemoglobin saturation (SPO2). Upper airway obstruction was diagnosed by clinical assessment by an experienced pediatric anesthesiologist (R.S.L.) and respiratory impedance plethysmography. RESULTS: During inhalation of N2O, 12 of the 20 children demonstrated a mild degree of ventilatory depression; PETCO2 values were equal to or greater than 45 mm Hg during at least 2 concentrations of N2O studied. There were no significant changes in SPO2 or PETCO2 with increasing concentrations of N2O (P > .05). Respiratory rates tended to be lower during inhalation of 15% N2O than at higher concentrations (P = .05). No child developed upper airway obstruction or hypoxemia (SPO2 < 92%) at any level of N2O inhalation. Sedation scores were significantly higher at 60% N2O than at all other concentrations of N2O (P < .02) At 15% N2O, 12 children were not clinically sedated, 8 children met the American Academy of Pediatrics definition of conscious sedation, and no child met the definition of deep sedation. At 30% N2O, 10 children were not clinically sedated, 9 met the definition of conscious sedation, and 1 child met the definition of deep sedation. At 45% N2O, 9 children were not clinically sedated, 9 met the definition of conscious sedation, and 2 met the definition of deep sedation. At 60% N2O, 6 children were not clinically sedated, 6 met the definition of conscious sedation, 6 met the definition of deep sedation, and 1 child progressed to a deeper level of sedation in that there was no response to a painful stimulus. One child was withdrawn from the study during inhalation of 45% N2O because of emesis. CONCLUSIONS: The combination of oral midazolam, 0.5 mg/kg, and up to 60% inhaled N2O caused mild ventilatory depression in some children and resulted in a progression from conscious to deep sedation beginning at 30% N2O. When using this particular combination of sedatives, practitioners should monitor each child's mental status continuously and adhere to the appropriate published guidelines for the monitoring and management of such patients.

Nucleus accumbens dopamine release increases during instrumental lever pressing for food but not free food consumption.

This experiment was undertaken to investigate the role of nucleus accumbens dopamine (DA) in instrumental and consummatory responses for food. In vivo microdialysis methods were used to study DA release and metabolism in the nucleus accumbens of behaving rats. Four behavioral conditions were used: performance on a fixed ratio 5 (FR 5) schedule of food reinforcement, consumption of Bioserve food pellets, consumption of laboratory chow, and food deprivation control. Groups of rats that were previously exposed to these conditions were implanted with dialysis probes in the nucleus accumbens and tested the day after implantation. The rats that pressed a lever on a FR 5 schedule showed significant increases in extracellular DA and DA metabolites compared to food-deprived control rats. In further analyses, rats that responded on the FR5 schedule were divided into three groups based upon their response rates. The rats with low response rates did not significantly differ from control rats, whereas rats with medium and high rates of responding showed significant increases in DA release relative to the control group. Rats that received massed presentation of food pellets or laboratory chow consumed large quantities of food, but showed no significant increases in DA release. This experiment demonstrated that performance of lever pressing behavior is accompanied by an increase in accumbens DA release and metabolism, and that DA release in nucleus accumbens is more closely related to the performance of highly active instrumental responses than it is to consumption of large quantities of food.

Oral findings in HIV-seropositive children.

The oral findings in 47 HIV-seropositive children are reported. The patient population consisted of 25 females and 22 males ranging in age from 3 months to 6.5 years. All patients were born to HIV-seropositive mothers. CDC classification of the patients indicated that 26 were P-O, 11 were P-1, and 10 were P-2 (eight of the P-2 patients met CDC criteria for AIDS). Oral candidiasis was the most common finding (six of 26 P-O patients and six of 10 P-2 patients). Only one patient each presented with parotid swelling and gingivitis. Mucosal lesions characteristic of viral infection were not observed in any of the patients.

Developmental orofacial deficits associated with multimodal cancer therapy: case report.

Multimodal cancer therapy for pediatric head and neck tumors may be associated with significant developmental orofacial morbidity. This report details these effects in a child (C.I.) diagnosed at 2.5 years of age with a rhabdomyosarcoma, primary to the left buccinator. This case is of interest as C.I. has an unaffected identical twin (D.I.) for comparative study. Both were assessed by comparing panoramic radiographs and lateral and frontal tracings of cephalometric radiographs obtained at 8.25 years of age. C.I. had multiple dental anomalies which included agenesis, ectopia, crown malformation, and root malformation. Root malformation, ectopia, and agenesis were restricted to the left dentition, whereas crown malformation was noted bilaterally. C.I. had a generalized craniofacial skeletal hypoplasia relative to D.I. in all three planes, growth defects were greater on the side of the tumor, and the mandible was affected more than the nasomaxillary complex.

Dental management of children with cancer.

Dental management of pediatric oncology patients is an important component of comprehensive supportive care. Oral complications associated with tumor directed treatment may be a direct result of the stomatotoxic effects of cancer therapy or the indirect effects of myelosuppression. These complications may be immediate or long-term. Appropriate dental supportive care has been shown to minimize the morbidity and potential mortality associated with these complications.