The Hall Technique 10 years on: its effect and influence.

Dental caries in early childhood can have a very significant effect not only on the oral health of young children but on their quality of life and that of their families. Added to this are the long-term infective risks to the host of untreated caries in primary teeth but also the risk of damage to successor permanent teeth. Traditional restoration of damaged primary teeth has been shown to have only moderate outcomes depending on the techniques and materials used and the ability of children to cooperate because of age or other factors. The Hall technique has outperformed other techniques in randomised clinical trials. In this Opinion Article I will take a look back at the Innes et al. paper, first published in this Journal in 2006, that introduced the Hall Technique and the subsequent scientific literature which provided us with high quality scientific evidence of the efficacy of the technique. I will evaluate how this new technique has affected the management of early childhood caries and hence its influence on wider oral and general health.

Sectioning of a double tooth aided by cone-beam computed tomography.

BACKGROUND: Double teeth present challenges for their clinical management. Recent advances in imaging, particularly cone-beam computed tomography (CBCT), have aided clinicians in accurate diagnosis and management. Data from CBCT imaging can be used for three-dimensional reconstruction to further aid pre-surgical planning. CASE REPORT: A 14-year-old Caucasian male presented with an aesthetically unacceptable double tooth in the 22 region. Clinical and radiographic examination and assessment included CBCT imaging and three-dimensional reconstruction. TREATMENT: Based on this information, together with a comprehensive assessment of the patient's motivation, a treatment plan consisting of extra-alveolar sectioning, re-implantation, endodontic therapy and composite resin restoration was carried out. FOLLOW-UP: The patient failed to return for follow-up at 6 months post-treatment. However, he did return at 12 months, where clinical and radiographic examination was undertaken. At this point the tooth was clinically sound and bony infill was seen radiographically. CONCLUSION: The information gained from the pre-surgical imaging with CBCT was useful in planning treatment in this case. However, this had to be combined with a careful assessment of the patient's motivation to ensure that the course of treatment embarked upon was likely to be successful whilst addressing the patient's concerns.

Early prognostic indicators and outcome prediction model for replanted avulsed teeth.

AIM: To identify early clinical variables that are most predictive of treatment outcome and to develop a model that will allow prediction of treatment outcomes based on these variables. STUDY DESIGN AND METHODS: A dental trauma database was used to randomly identify patients who had received treatment for avulsed teeth between 1998 and 2007. A data extraction form was designed and completed for each tooth. Demographic, diagnostic and treatment information recorded in the patient's records, in addition to radiographs, were viewed retrospectively. STATISTICS: The significance and the predictive power for each early clinical variable were assessed using a univariate logistic regression model. Only significant variables (p<0.05) were considered eligible for the prediction model and a c-index was then constructed for their respective predictive power (0.5 = no predictive power, 1.0 = perfect prediction). RESULTS: Of the original sample of 213 patients who had received treatment for avulsed teeth between 1998-2007 only 105 fulfilled the criteria for evaluation. Two models ('At first visit' and 'at initial treatment visits') were produced with a total of five variables that were significant and holding the greatest predictive power (high c-index): patient age (p=0.001, c=0.80); stage of root formation (p=0.001, c=0.76); storage medium (p=0.047, c=0.58); tooth mobility after dressing (p=0.001, c=0.70); and tooth mobility after splinting (p=0.003, c=0.70). These variables underwent multi-variate analysis and the final models had good predictive abilities (c-index of 0.80 and 0.74). CONCLUSION: These predictive models based on patient age, stage of root formation, storage medium, tooth mobility after dressing and tooth mobility after splinting were shown to have high predictive value and will enable a clinician to estimate the long term prognosis of avulsed and replanted teeth. It will enable planning for further treatment with a realistic view of outcome at an early stage.

An investigation into infant feeding in children born with a cleft lip and/or palate in the West of Scotland.

AIM: To investigate feeding practices in infants born with a cleft lip and/or palate (CLP) in the West of Scotland and the challenges that the parents of these children experienced especially in the first hours and months after birth. METHODS: A questionnaire involving a 'face-to-face' interview was completed with parents of cleft children under the age of 6 years with a cleft lip and/or palate attending the Oral Orthopaedic Prevention Clinic (OOPC). RESULTS: 90 questionnaires were completed and analysed. The incidence of breastfeeding in this study at birth was 54%. In comparison, the incidence of breastfeeding in Scotland nationally was 63% in the year 2000 and 70% in 2005 indicating a lower uptake of breastfeeding for this CLP population. Cleft type had a significant impact on whether the infant was breastfed (p<0.05), those with a cleft lip being more likely to be breastfed. Twenty-nine percent of cleft infants required the use of a naso-gastric tube (NGT) to assist feeding either in hospital during the days following birth or later when there were concerns about the infant's weight. Of these all but one had a CP+/- CL, (p<0.001); 26% of parents reported that their infant had used a pre-surgical appliance; 70% rated the appliance highly in terms of aiding feeding. The help and support given by the cleft team, especially Specialist Cleft Nurses (SCNs), was rated as positive in over 95% of cases but was less positive for the non-cleft health care professionals. Parents found it difficult to find the right feeding method for their baby until they received input from the SCNs and only a minority of parents managed to establish a regular feeding pattern. CONCLUSIONS: This study recommends the employment of more SCNs and an improvement of the knowledge of non-cleft health care professionals.

Dental caries prevalence in children with cleft lip/palate aged between 6 months and 6 years in the West of Scotland.

AIM: To compare the prevalence of dental caries in children with cleft lip/palate with national data at the same age. METHOD: Ethical approval was granted from the West of Scotland Ethics Committee. Children attending the Oral Orthopaedic Clinic were examined for caries according to the criteria of the British Association for the Study of Community Dentistry (BASCD) by two trained and calibrated examiners (KB, RW). Subjects were divided into five age groups: 0.5-1.49; 1.5-2.49; 2.5-3.49; 3.5-4.49 and 4.5-6.0 years. Mean dmft scores were compared with available national data (National Dental Inspection Program of Scotland) for nursery [NDIP 3-year-old survey 2008, unpublished] and 5-year-old children in Scotland [NDIP, 2008]. RESULTS: 209 subjects were examined (participation rate of 87.4%); 45.9% were female, 54.1% male; 21 children (10%) had a recognised syndrome and were reported separately. Cleft Palate (CP) was the most commonly occurring cleft in both syndromic and non-syndromic groups, followed in decreasing numbers by Unilateral Cleft Lip and Palate (UCLP), Bilateral Cleft Lip and Palate (BCLP), Unilateral Cleft Lip (UCL) and Bilateral Cleft Lip (BCL). The only age group with a significantly higher level of dental caries compared with national data was the 4.5-6.0 year-olds where only 37.2% of the children with clefts were caries free compared with the national figure of 57.7% (p=0.004). This same age group had a mean dmft for the cleft group of 3.24 compared with 1.86 nationally. The other age groups had similar dmft and percentages of subjects caries free compared with the national data. The differences did not reach significance. Caries was more common in the anterior teeth of the youngest two age groups, but in the posterior teeth of the two oldest age groups. CONCLUSION: By the age of 4.5 years, children with cleft lip/palate in the West of Scotland have significantly more caries than their non-cleft peers.

Literature review: Restorations of class II cavities in the primary dentition with compomers.

BACKGROUND: A large number of studies concerning the use of compomers in class II cavities in the primary dentition already exist, but the variety of the research perspectives is even bigger. AIM: This study therefore intends to abridge and evaluate the existing research through a systematic literature review. METHODS: In order to gather relevant articles an extended literature research was carried out. The criteria for the evaluation of the resulting articles were based on the article of Kilpatrick and Neumann [2007]. RESULTS: According to the subject of the research, the articles were divided into the following groups: PAM-C; PAM-C and amalgam; PAM-C and GIC; PAM-C and hybrid composites; PAM-C and pre-treatment. CONCLUSIONS: The findings lead to the conclusion that PAM-C can be an alternative to other restorative materials in the primary dentition in class II cavities, except in the case of teeth with pulpectomies or pulpotomies. The placement of compomers takes longer than placing amalgam, but the procedure consists of fewer steps compared to composites. However, patient-compliance remains essential.

Case report: Cone-beam ct imaging in the management of a double tooth.

BACKGROUND: The diagnosis and management strategies of double teeth have largely relied on clinical examination and conventional radiographic findings. Cone-Beam Computed Tomography (Cone-beam CT) was developed in the late 1990's and, therefore, is a relatively recent addition to the imaging armamentarium for use in Maxillofacial Radiology. There have been no publications in the dental literature demonstrating the use of Cone-beam CT or 3D stereolithography in the diagnosis and surgical planning of the management of double teeth. CASE REPORT: An 11 year old girl presented with a double left lateral maxillary incisor. Conventional plain film radiography failed to provide the requisite information for pre-operative planning. Cone-beam Computed Tomography (Cone-beam CT) allowed determination of location of fusion, three-dimensional (3D) visualisation of pulpal anatomy and the construction of a 3D stereolithographic model for surgical planning. The double tooth was surgically divided in situ under local analgesia. The redundant distal unit was extracted and the residual mesial unit built up in composite resin following physiological mesial drift of displaced maxillary left canine. No endodontic therapy was required. FOLLOW-UP: At a 10-month follow-up visit, clinical and radiographic vitality and success was noted. CONCLUSION: The great amount of radiological information which Cone-beam CT can offer not only improves pre-operative and surgical planning, but the 3D models provided can be used to further educate and inform patients and guardians in the management of double teeth.

Safeguarding children in dentistry: 2. Do paediatric dentists neglect child dental neglect?

In this second part of a two-part report, further findings of a postal questionnaire sent in March 2005 to dentists with an interest in paediatric dentistry working in varied UK settings are presented and discussed in the context of current multi-agency good practice in safeguarding and promoting the welfare of children. Using insights gained from a survey of self-reported management of children with neglected dentitions, this paper explores whether paediatric dentists neglect child dental neglect. The authors conclude that current practice already includes much that contributes to promoting children's oral health and wellbeing. However, in a society where children continue to suffer as a result of abuse and neglect, they warn that improvements are needed in communication between dentists and other health and social care professionals if children's welfare is to be safeguarded and promoted effectively and future tragedies avoided.

Safeguarding children in dentistry: 1. Child protection training, experience and practice of dental professionals with an interest in paediatric dentistry.

Following several highly publicised inquiries into the deaths of children from abuse and neglect, there has been much recent interest in the role and responsibility of all health professionals to protect children at risk of maltreatment. The findings of a postal questionnaire, sent in March 2005 to 789 dentists and dental care professionals with an interest in paediatric dentistry working in varied settings in the UK, are presented in a two-part report and discussed in the context of current multi-agency good practice in safeguarding and promoting the welfare of children. This first part explores reported child protection training, experience and practice. There was a significant gap between recognising signs of abuse and responding effectively: 67% of respondents had suspected abuse or neglect of a child patient at some time in their career but only 29% had ever made a child protection referral. The dental profession is alerted to the need to ensure necessary appropriate action to safeguard children is always taken when child abuse or neglect are suspected.

A randomised placebo-controlled trial of the effects of midazolam premedication on children's postoperative cognition.

This randomised, placebo-controlled study assessed the effects of midazolam premedication on children's postoperative cognition and physical morbidity. In all, 179 children aged 5-10 years were randomly assigned to receive buccal midazolam (0.2 mg x kg(-1)) or placebo before sevoflurane-nitrous oxide anaesthesia for multiple dental extractions. They performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), before discharge and at 48 h. The reaction time of both groups was significantly slower before discharge compared to baseline, with the midazolam group being significantly slower than placebo. Psychomotor co-ordination was also significantly impaired postoperatively after midazolam. Performance on both tests had recovered to baseline by 48 h. Midazolam was also associated with significant anterograde amnesia, both postoperatively and at 48 h, for information presented in the interval between premedication and surgery. The results show significant short-term impairment of children's cognitive function and amnesia enduring for 48 h after low-dose midazolam premedication.

Comparison of transmucosal midazolam with inhalation sedation for dental extractions in children. A randomized, cross-over, clinical trial.

BACKGROUND: The transmucosal route for conscious sedation in children has been reported widely in the field of medicine, but less so in dental patients. The aim of this study was to evaluate the efficacy and safety profile of midazolam (0.2 mg/kg) administered by the buccal transmucosal route, in comparison with nitrous oxide/oxygen inhalation sedation, for orthodontic extractions in 10-16-year-old dental patients. METHODS: Each patient attended for two visits and was randomly allocated to receive buccal midazolam (0.2 mg/kg) or nitrous oxide/oxygen titrated to 30%/70% at the first visit, the alternative being used at the second visit. The patients' vital signs, sedation levels and behavioural scores were recorded throughout. Post-operatively, side-effects, recall of the visit and satisfaction levels were recorded via questionnaire. RESULTS: Thirty-six patients, with a mean age of 12.9 years, completed both arms of the trial. The maximum level of sedation was achieved with buccal midazolam in a mean time of 14.42 min, compared with 7.05 min with inhalation sedation. The vital signs with both types of sedation remained within acceptable limits and the reported side-effects were of no clinical significance. Buccal midazolam was found to be acceptable by 65.7%. Only 28.6% of cases preferred this technique, the main disadvantage being the taste of the solution. CONCLUSION: Buccal midazolam sedation (0.2 mg/kg) seems to be equally as safe and effective as nitrous oxide/oxygen for the extraction of premolar teeth in anxious children. However, further research is required to refine the midazolam vehicle to improve acceptability.

The dental health and preventative habits of cardiac patients attending the Royal Hospital for Sick Children Glasgow.

AIM: To assess the dental health and preventive practices of child patients with congenital heart disease treated at the Royal Hospital for Sick Children, Glasgow. STUDY DESIGN: A retrospective study using an audit data collection sheet. METHODS: Data collected for 370 paediatric cardiac patients between January 2002 and December 2003 was analysed to obtain an insight into these patients' tooth brushing methods, use of fluoride (F), dental attendance and past dental treatment. An oral examination assessed the patient's caries experience. RESULTS: There were 195 subjects aged between 1 and 5 years, 105 were 6 - 11 years and 70 were 12 -16 years of whom 291 (78%) children were registered for dental care. Of these children 331 (90%) maintained that they brushed their teeth regularly with F- toothpaste. Experience of dental treatment revealed that 132 (36%) children had undergone previous dental treatment. Oral examination showed that out of 370 patients, 236 (64%) had no active caries. The dental health of the cardiac subjects was poor compared with that of Scottish primary school children (5 year-olds) and the 12 year-olds but compared favourably with the 14-year old group. STATISTICS: The relationship between caries activity and frequency of toothbrushing was significant (p<0.01). The relationship between caries activity and attendance for dental care was not significant. CONCLUSION: Children with cardiac problems should be identified in early infancy through liaison with medical colleagues and the family offered all the preventive advice and regular dental care necessary to prevent dental disease.

A comparison of oral midazolam and nitrous oxide sedation for dental extractions in children.

The aim of the study was to compare oral midazolam and inhaled nitrous oxide as sedative agents during the management of children aged 5-10 years presenting for extraction of primary teeth under local anaesthetic. Subjects required two visits for the extraction of four primary teeth, one in each quadrant of the mouth, and were randomly allocated to be given nitrous oxide 30% in oxygen or oral midazolam 0.3 mg.kg(-1) at the first visit, the other technique being used at the second visit. Vital signs, sedation levels and behavioural scores were recorded, and postoperative recall and satisfaction were reported by the patients. Thirty-five children, with a mean [range] age of 7.4 [5-10] years, completed the treatment. The mean dose of oral midazolam given was 8.6 [3.3-16.5] mg. The mean times taken to achieve the maximum level of sedation for midazolam and nitrous oxide sedation were 15.9 [2-30] min and 6.8 [2-10] min, respectively. Physiological parameters remained within acceptable clinical limits for both types of sedation. Oral midazolam was considered acceptable by 59% and was preferred by 36%. Oral midazolam sedation in 5 to 10-year-old children was shown to be as safe and effective as nitrous oxide in oxygen sedation for extraction of primary teeth but would not be the method of choice for all patients.

Dietary and social characteristics of children with severe tooth decay.

BACKGROUND AND AIMS: Dental decay remains a major public health problem in Scottish children. The aim of this study was to investigate the relationship between diet, bowel habit, social class, and body mass index (BMI) in children with severe tooth decay. CHILDREN AND METHODS: A cross sectional study of 165 children aged 3 -11 years attending Glasgow Dental Hospital for extraction of teeth under dental general anaesthesia (DGA), was undertaken. A structured questionnaire was used to obtain information from each child on diet, bowel habit, and social status of their parents. Fibre and sugar scores were calculated from the frequency of consumption of a range of relevant foods. RESULTS: The children (mean age 5.7 (SD1.8) years) had between 1 and 20 decayed, missing or filled primary teeth (dmft) with a mean dmft of 7.9 (SD 3.5). 37% ate a chocolate bar daily, and 29% regularly drank a sugary drink after brushing their teeth. An excess of children were from the most deprived parts of the city and they had the worst decay. Children with the worst decay were also significantly thinner. No relationship was found between tooth decay and bowel habit. CONCLUSIONS: In this selected group of children with poor dental health, those from deprived families were over-represented and had significantly more decay. Severe dental decay was also associated with underweight.

Treatment of aesthetic problems in paediatric dentistry.

Aesthetic problems in childhood and adolescence can have a significant effect on psychosocial development and interaction with peers. Abnormalities of shape, size, colour and structure of the whole or part of the anterior dentition of children can lead to such problems. This article outlines the most appropriate options for the clinical management of different aetiological categories of aesthetic problems, and develops a hierarchy of intervention that should be pursued in a logical order until a satisfactory cosmetic outcome is achieved. These techniques are readily available to most dental practitioners and there is no reason for a child to have to wait until late adolescence for treatment. Dent Update 2003; 30: 307-313 CLINICAL RELEVANCE: Aesthetic problems in children and adolescents may be treated by a variety of techniques.

The effects of brief sevoflurane-nitrous oxide anaesthesia upon children's postoperative cognition and behaviour.

This study assessed the effects of brief sevoflurane-nitrous oxide anaesthesia on children's postoperative cognition, behaviour and physical morbidity. Forty-eight children aged 5-10 years undergoing anaesthesia without premedication for multiple dental extractions, and 48 control children, performed tests of choice reaction time, attention, psychomotor co-ordination and memory pre-operatively (baseline), prior to discharge and at 48 h (anaesthesia group only). Physical and psychological morbidity were recorded at 1 week. Mean choice reaction time and psychomotor co-ordination were significantly impaired postoperatively but had recovered at 48 h. However, measures of performance variability suggested the presence of residual impairment. Profound retrograde amnesia affected postoperative and 48-h recall of pictorial stimuli presented prior to anaesthesia, but recognition memory was unimpaired. Attention-seeking, tantrums, crying and nightmares were occurring more frequently in some 8-20% of children 1 week after the procedure.

The dental practitioner and child protection in Scotland.

OBJECTIVES: To identify from general dental practitioners: undergraduate and postgraduate training experience in child protection; numbers of suspected cases of child physical abuse; reasons for failing to report suspicious cases of child physical abuse; knowledge of local child protection protocols and procedures for referral. MATERIALS AND METHODS: Postal questionnaires were sent to 500 randomly selected general dental practitioners in Scotland, with a further 200 sent to a random sample of the original 500 to increase response rate. RESULTS: Sixty-one per cent (306) of the original 500 questionnaires, and 35% (69) of the second random mail shot of 200 questionnaires were returned. Only 19% could remember any undergraduate training and 16% had been to a postgraduate lecture or seminar in child protection. Twenty-nine per cent of dentists had seen at least one suspicious case in their career. Only 8% of suspicious cases were referred on to the appropriate authorities. Reasons for failure to refer revealed that 11% were concerned about a negative impact on their practice, 34% feared family violence towards the child, 31% feared violence directed against them, and 48% feared litigation. Only 10% of dentists had been sent a copy of the local child protection guidelines on commencing work and only 15% had seen their Area Child Protection Committee (ACPC) Guidelines via any route. CONCLUSIONS: Due to lack of training or clear guidelines for dentists in Scotland, most practitioners were unsure what to do in the event of a suspicion of child abuse. Twenty-one per cent of dentists had encountered suspicious cases but failed to take any action. Dentists overwhelmingly requested appropriate training. This training should address dental competence in assessment of suspicious indicators and involve dentists in inter-agency child protection training.