Phase Four, Randomized, Double-Blinded, Controlled Trial of Phentolamine Mesylate in Two- to Five-year-old Dental Patients.

PURPOSE: The purpose of this study was to evaluate, using a randomized, double-blind methodology: (1) the safety of phentolamine mesylate (Oraverse) in accelerating the recovery of soft tissue anesthesia following the injection of two percent lidocaine plus 1:100,000 epinephrine in two- to five-year-olds; and (2) efficacy in four- to five-year-olds only. METHODS: One hundred fifty pediatric dental patients underwent routine dental restorative procedures with two percent lidocaine plus 1:100,000 epinephrine with doses based on body weight. Phentolamine mesylate or a sham injection (two to one ratio) was then administered. Subjects were monitored for safety and, in four- to five-year-olds, for efficacy during the two-hour evaluation period. RESULTS: There were no significant differences in adverse events between the phentolamine and sham injections. Compared to sham, phentolamine was not associated with nerve injury, increased analgesic use, or abnormalities of the oral cavity. Phentolamine was associated with transient decreased blood pressure in some children. In four- and five-year-olds, phentolamine induced more rapid recovery of lip anesthesia by 48 minutes (P<0.0001). CONCLUSIONS: Phentolamine was well tolerated and safe in three- to five-year-olds; in four- to five-year-olds, a statistically significant more rapid recovery of lip sensation compared to sham injections was determined.

Mucoepidermoid carcinoma of the palate in adolescence.

Although relatively rare, minor salivary gland tumors are more likely to be malignant in pediatric patients than in adults. Mucoepidermoid carcinoma (MEC) represents the most common malignant tumor of the salivary glands. It is critical to differentiate such tumors from common benign salivary gland lesions. The purposes of this report are to present the case of a 15-year-old female with MEC of the palate, and to discuss the importance of a thorough intraoral examination on all patients regardless of age, as well as the need for timely referral for appropriate diagnosis and treatment.

Breastfeeding, co-sleeping and dental health advice.

PURPOSE: To identify dental health advice offered by healthcare providers (HCPs) to mothers that cosleep and breastfeed at night. STUDY DESIGN AND METHODS: Mothers were recruited via local contacts, e-mail, and support groups. In-person, digitally recorded interviews were conducted with 14 cosleeping, breastfeeding mothers with children from 6 months to 2 years. Interviews included seven open-ended questions about cosleeping patterns, night breastfeeding patterns, and dental health advice offered by HCPs. These HCPs included pediatricians, family medicine physicians, midwives, and obstetricians. Interviews were transcribed verbatim and qualitative descriptive analysis was done. RESULTS: The majority of women reported keeping their child in bed with them for most, if not all, of the night. All of the mothers reported breastfeeding on demand. Approximately half of the mothers did not disclose their sleeping patterns to their HCP. Mothers reported few HCPs initiated a discussion on cosleeping or oral hygiene for their child. CLINICAL IMPLICATIONS: Mothers did not readily share their cosleeping, nor did most HCPs initiate a conversation about cosleeping and dental hygiene. This qualitative study identifies the need for education on anticipatory guidance of oral hygiene discussions from HCPs. As HCPs, it is our responsibility to initiate the conversation with the mother because this study demonstrates that mothers will be unlikely to do so.

Anesthetic and dental management of a child with IMAGe syndrome.

IMAGe syndrome (OMIM 300290) is a rare multisystem disorder that has a broad phenotypic presentation. Though variable, this disorder mainly consists of Intrauterine growth retardation, Metaphyseal dysplasia, Adrenal hypoplasia congenita, and Genital abnormalities. Patients with IMAGe syndrome present as an uncommon yet important challenge for dentists and anesthesiologists due to their wide range of dysmorphic facial features, adrenal insufficiency, electrolyte imbalances, and need for steroid replacement. The purpose of this case report is to describe the successful anesthetic management of a pediatric patient diagnosed with IMAGe syndrome who presented for full mouth dental rehabilitation.

Shear bond strength of dentin and deproteinized enamel of amelogenesis imperfecta mouse incisors.

PURPOSE: The purposes of this study were to: (1) investigate adhesion through shear bond strength (SBS) testing of a resin composite bonded with a self-etching bonding system (SEB) to amelogenesis imperfecta (AI)-affected deproteinized mouse enamel or dentin; and (2) compare wild-type (WT), amelogenin null (AmelxKO), and matrix metalloproteinase-20 null (Mmp20KO) enamel and dentin phenotypes using micro-CT and nanoindentation. METHODS: Enamel incisor surfaces of WT, AmelxKO, and Mmp20KO mice were treated with SEB with and without sodium hypochlorite and tested for SBS. Incisor dentin was also treated with SEB and tested for SBS. These surfaces were further examined by scanning electron miscroscopy. Micro-CT and nanoindentation analyses were performed on mouse dentin and enamel. Data were analyzed for significance by analysis of variance. RESULTS: Deproteinization did not improve SBS of SEB to these AI-affected enamel surfaces. SBS of AmelxKO teeth was similar in dentin and enamel; however, it was higher in Mmp20KO dentin. The nanohardness of knockout enamel was significantly lower than WT, while knockout dentin nanohardness was not different from WT. CONCLUSIONS: Using animal amelogenesis imperfecta models, enamel sodium hypochlorite deproteinization of hypoplastic and hypoplastic-hypomaturation enamel did not increase shear bond strength, while removal of the defective enamel allowed optimal dentin bonding.

Evaluation of bronchial asthma as risk factor for early childhood caries.

Asthma and dental caries are common chronic health conditions of childhood. The aim of this study was to determine if severity of bronchial asthma is a risk factor for early childhood caries. Asthmatic children aged 71 months or younger were examined for their plaque and caries status and were compared with controls matched for age, sex and socioeconomic status. The results showed that asthmatics as a group had a lower DMFT score than the control group. New asthma management and educational programs may be having a positive spillover effect to the dental arena.

Oral factitious injury in a child diagnosed with Kabuki syndrome.

Factitious injury or self-injurious behavior is a common manifestation in children affected by neurologic, developmental, or psychiatric disease. The nature and presentation of this behavior in the oral cavity varies among diagnoses, and such behavior can be easily missed. This report describes the presence of self-injurious behavior in a child diagnosed with Kabuki syndrome who presented to a pediatric dentistry referral practice for evaluation of gingival bleeding, and provides a brief overview of the known etiology and management of this challenging condition. Clinicians should be aware of the possibility of self-injurious behavior when treating children diagnosed with Kabuki syndrome.

Evaluation of bronchial asthma as risk factor for early childhood caries.

Asthma and dental caries are common chronic health conditions of childhood. The aim of this study was to determine if severity of bronchial asthma is a risk factor for early childhood caries. Asthmatic children aged 71 months or younger were examined for their plaque and caries status and were compared with controls matched for age, sex and socioeconomic status. The results showed that asthmatics as a group had a lower DMFT score than the control group. New asthma management and educational programs may be having a positive spillover effect to the dental arena.

A survey of senior dental students' experiences with young dental patients in Pennsylvania.

The purpose of this study was to determine graduating dental students' perceptions about their training and experience in examination and treatment of infants and their plans to examine infants upon graduation. A survey was distributed to dental students graduating from Pennsylvania dental schools in 2007 and 2008. Of the returned surveys, 47.9 percent correctly identified 12 months as the recommended age for the first dental exam. Sixty-five percent of responders felt they would be comfortable performing exams on young children. This study's primary objective was to test the association between performance of a clinical exam in a young child, enjoyment of clinical and didactic pediatric dental experience, plans for additional training in pediatric dentistry and willingness to see children younger than two years old in practice. Performing a clinical exam on a young child was associated to willingness to see children younger than two years of age in practice. Early exposure (lecture or clinical) to young pediatric patients while in dental school was significantly associated to perceived comfort with oral exam of young patients but not to reported willingness to see them in practice.

Phentolamine mesylate for accelerating recovery from lip and tongue anesthesia.

Phentolamine mesylate, at dosages from 0.4 to 0.8 mg in adults and adolescents and at dosages from 0.2 to 0.4 mg in children aged 4 to 11 years, has been proven to be safe and effective for the reversal of soft tissue anesthesia (lip and tongue numbness) and the associated functional deficits resulting from a local dental anesthetic injection containing a vasoconstrictor. Its ability to block a-adrenergic receptors on blood vessels induces vasodilation and enhances the redistribution of the local anesthetic away from the injection site. The low dosages administered for dental local anesthetic reversal in all likelihood accounts for the lack of significant cardiovascular effects that are associated with the medical use of the drug for hypertensive conditions associated with catecholamine excess.

Amelogenesis imperfecta due to a mutation of the enamelin gene: clinical case with genotype-phenotype correlations.

The major protein components of the enamel matrix include the most abundant amelogenin proteins as well as less plentiful proteins such as enamelin and ameloblastin. The enamel defect in amelogenesis imperfecta (Al) generally results in enamel that is too thin (hypoplastic) or too soft (hypocalcification or hypomaturation). Previous reports indicate that mutations in the human enamelin gene (ENAM) cause hypoplastic Al through autosomal-dominant inheritance patterns and patients may also exhibit an anterior open bite. Although crown resorption of unerupted teeth occurs more frequently in Al patients, this finding has not been previously associated with known ENAM mutations. The purpose of this article was to report the genotype-phenotype correlations for a 9-year, 11-month-old boy with a homozygous ENAM mutation (c.1258_1259insAG).

Dental and anaesthetic management of children with dystrophic epidermolysis bullosa.

BACKGROUND: Epidermolysis bullosa (EB) is a genetic disease associated with fragility and bullous lesions of the skin and mucous membranes. There are various patterns of inheritance and histopathology. The disease is associated with systemic and oral manifestations, among which may be dental decay necessitating oral rehabilitation. General anaesthesia is frequently required for oral rehabilitation in children with dystrophic EB. Paediatric dentists should be aware of the implications of dystrophic EB for dental and anaesthetic management. CASE REPORT: Two siblings with moderate to severe systemic and oral manifestations of dystrophic EB requiring extensive oral rehabilitation for rampant decay are described, including special anaesthetic techniques required for airway management and maintenance of skin integrity. CONCLUSION: Dystrophic EB is a rare genetic disorder in which vesiculobullous lesions occur with erosions and scarring of cutaneous and extracutaneous surfaces in the oral cavity. Poor oral hygiene results from efforts to avoid mucosal trauma, resulting in decay. The comprehensive care of children with dystrophic EB impacts not only dental management but anaesthesia administration as well.

Dental management of a child with congenital sideroblastic anemia: a case report.

The sideroblastic anemias comprise a heterogeneous group of acquired and congenital disorders which that have in common: (1) anemia; (2) the presence of ring sideroblasts in the bone marrow; and (3) impaired heme biosynthesis. Elevation in iron levels is secondary to a deficiency in mitochondrial physiology. Patients exhibit mild to moderate hemolysis due to peripheral red blood cell destruction, and often require regular blood transfusions. The purpose of this case report was to describe the dental management of a child with congenital sideroblastic anemia--a rare hematologic disorder--and to emphasize how important it is for pediatric dentists to be cognizant of a patient's hematologic profile before attempting to perform any dental procedure. The timing of the patient's transfusions regarding the scheduling of dental care is crucial for successful management and anticipation of possible complications. Preventive dentistry should be a hallmark of dental management for these children.

The use of stock fluoride trays in the management of soft tissue trauma in children who are comatose.

Pediatric patients who are comatose may develop a neuropathological chewing or clenching reflex that results in self-inflicted injury to the soft tissues of the oral cavity. An early and quick response to these problems may minimize the extent of soft tissue trauma. The use of a stock fluoride tray in the hospital management of a pediatric patient who was neurologically impaired and unconsciously traumatizing his oral soft tissues is described. This treatment modality may serve as an initial or interim device in managing pediatric patients with uncoordinated mandibular movements or clenching. In some instances, given the sometimes self-limiting nature of this problem, fluoride trays may serve as the sole mode of treatment

Management of a young patient with combined autoimmunity: Evans syndrome: a case report.

Management of patients with autoimmune disease can present a challenge for clinicians. Combinations of autoimmune disorders carry a worse prognosis and are often difficult to diagnose. Evans syndrome is a rare hematologic disorder characterized by the concurrent presentation of autoimmune hemolytic anemia and immune thrombocytopenic purpura. This paper reports the first case of the dental management of a young patient with Evans, discusses the current literature surrounding the differential diagnosis and treatment of Evans syndrome, and suggests a guide for the oral medicine, pediatric dentist, or hospital dental clinician when treating these patients.

The PFAPA syndrome in oral medicine: differential diagnosis and treatment.

Periodic fever syndromes in children can present with orofacial manifestations which contribute to the formulation of a differential diagnosis. Because of the early onset of oral lesions in these syndromes, the oral medicine practitioner may be required to assist in their diagnosis and management. The periodic fever, aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome has been classified as a type of periodic fever syndrome ocurring in early childhood. This article presents a review of the published literature on this entity and summarizes current therapeutic options.

TRAIL in the airways.

Tumor necrosis factor-related apoptosis inducing ligand (TRAIL) is an important immunomodulatory factor that may play a role in the structural changes observed in the asthmatic airways. In vitro as well as in vivo studies have evidenced a dual role for TRAIL: it can either function as a pro- or anti-inflammatory cytokine on inflammatory cells, participating in the initiation and resolution of inflammatory and immune responses. TRAIL is expressed in the airways by inflammatory cells infiltrated in the bronchial mucosa, as well as by structural cells of the airway wall including fibroblasts, epithelial, endothelial, and smooth muscle cells. By releasing TRAIL, these different cell types may then participate in the increased levels of TRAIL observed in bronchoalveolar lavage fluid from asthmatic patients. Taken together, this suggests that TRAIL may play a role in inflammation in asthma. However, concerning its role is dual in the modulation of inflammation, further studies are needed to elucidate the precise role of TRAIL in the airways.

Differential expression of TRAIL and TRAIL receptors in allergic asthmatics following segmental antigen challenge: evidence for a role of TRAIL in eosinophil survival.

Asthma is a chronic lung disease exhibiting airway obstruction, hyperresponsiveness, and inflammation, characterized by the infiltration of eosinophils into the airways and the underlying tissue. Prolonged eosinophilic inflammation depends on the balance between the cell's inherent tendency to undergo apoptosis and the local eosinophil-viability enhancing activity. TRAIL, a member of the TNF family, induces apoptosis in most transformed cells; however, its role in health and disease remains unknown. To test the hypothesis that Ag-induced inflammation is associated with TRAIL/TRAIL-R interactions, we used a segmental Ag challenge (SAC) model in ragweed-allergic asthmatics and nonasthmatic patients and analyzed bronchoalveolar lavage (BAL) material for 2 wk. In asthmatic patients, the level of TRAIL in BAL fluid dramatically increased 24 h after SAC, which significantly correlated with BAL eosinophil counts. Immunohistochemical analysis of bronchial biopsies from asthmatic patients demonstrated that TRAIL staining was increased in epithelial, airway smooth muscle, and vascular smooth muscle cells and throughout the interstitial tissue after SAC. This was confirmed by quantitative immunocytochemical image analysis of BAL eosinophils and alveolar macrophages, which demonstrated that expression levels of TRAIL and DcR2 increased, whereas expression levels of the TRAIL-Rs DR4 and DR5 decreased in asthmatic subjects after SAC. We also determined that TRAIL prolongs eosinophil survival ex vivo. These data provide the first in vivo evidence that TRAIL expression is increased in asthmatics following Ag provocation and suggest that modulation of TRAIL and TRAIL-R interactions may play a crucial role in promoting eosinophil survival in asthma.

Ewing's sarcoma of the mandible: a combined approach to treatment.

Ewing's Sarcoma (ES) is a malignant tumor, which arises primarily in children. Most commonly found in the long bones and pelvis, it rarely is found in the bones of the face. This is a report of ES of the mandible in a nine-year-old Caucasian female. Treatment for this malignancy included an incisional biopsy, chemotherapy and radiotherapy protocol to the involved area in accordance with St. Christopher's Hospital and the Children's Hospital of Philadelphia. The patient is currently disease-free and has been for approximately five years.