The face of a child: children's oral health and dental education.

Dental care is the most common unmet health care need of children. Those at increased risk for problems with oral health and access to care are from poor or minority families, lack health insurance, or have special health care needs. These factors place more than 52 percent of children at risk for untreated oral disease. Measures of access and parental report indicate unmet oral health needs, but do not provide guidance as to the nature of children's oral health needs. Children's oral health needs can be predicted from their developmental changes and position in the life span. their dependency and environmental context, and current demographic changes. Specific gaps in education include training of general dentists to care for infants and young children and those with special health care needs, as well as training of pediatric providers and other professionals caring for children in oral health promotion and disease prevention. Educational focus on the technical aspects of dentistry leaves little time for important interdisciplinary health and/or social issues. It will not be possible to address these training gaps without further integration of dentistry with medicine and other health professions. Children's oral health care is the shared moral responsibility of dental and other professionals working with children, parents, and society. Academic dental centers hold in trust the training of oral health professionals for society and have a special responsibility to train future professionals to meet children's needs. Leadership in this area is urgently needed.

Deficits versus strengths: ethics and implications for clinical practice and research.

A shift in emphasis from deficits to strengths to promote health and well-being in patients with congenital and acquired craniofacial conditions (CFC) is appropriate given the chronic, "incurable" nature of CFC. Personal narratives are a valuable starting point for discovering sources of resilience. This paper explores such a shift by considering two areas of ethical concern suggested by patient narratives: informed consent and the physician-patient relationship. Both areas contain pitfalls and opportunities. The powerful emotions these patients bring with them argue for caution in medical decision making. Attention to the individual's psychosocial adjustment should always supplement surgical evaluations. Because of the inequality of the physician-patient relationship, care should be taken to use this power in positive ways. The relationship between patient and surgeon is particularly charged and may be an important source of support, information, hope, and advice for patients. The changing health care system threatens the physician-patient relationship, but the rise of alternative medicine suggests patients continue to value relationships. Relationships are critical for individuals with CFC, who experience social rejection because of the fundamental importance of face in human interactions. Future research directions should include long-term outcome studies on patients receiving modern craniofacial team care, qualitative research on resilience in patients with positive life adjustment, and development of a conceptual framework and research methodology for understanding quality of life of individuals with CFC. An emphasis upon strengths rather than defects will have implications for the structure of craniofacial teams, the care that is provided, and allocation of resources.

Do children get their fair share of health and dental care?

This paper reviews the work of several authors, D.W. Brock, D. Callahan, L. Churchill, L.M. Kopelman, R. Tong who consider assumptions and arguments about how to allocate health and dental care to children fairly. They use various approaches including feminist, rights based, and principled considerations, applying general notions of duty or justice to the issues of children's access to basic health and dental care. Two discuss these issues in relation to the work of David Hume. These authors consider children's greatest unmet health needs, including that of dental care, often mistakenly regarded as medically unimportant in terms of children's wellbeing, opportunities, and self-image. They review possible age bias against children in the allocation of health and dental care, the gap between what we say and do where children are concerned, and whether some fundamental shift in social thinking needs to occur.

Disparities in children's oral health and access to dental care.

Dental caries can be prevented by a combination of community, professional, and individual measures including water fluoridation, professionally applied topical fluorides and dental sealants, and use of fluoride toothpastes. Yet, tooth decay is the most common chronic disease of childhood. Dental care is the most prevalent unmet health need in US children with wide disparities existing in oral health and access to care. Only 1 in 5 children covered by Medicaid received preventive oral care for which they are eligible. Children from low income and minority families have poorer oral health outcomes, fewer dental visits, and fewer protective sealants. Water fluoridation is the most effective measure in preventing caries, but only 62% of water supplies are fluoridated, and lack of fluoridation may disproportionately affect poor and minority children. Childhood oral disease has significant medical and financial consequences that may not be appreciated because of the separation of medicine and dentistry. The infectious nature of dental caries, its early onset, and the potential of early interventions require an emphasis on preventive oral care in primary pediatric care to complement existing dental services. However, many pediatricians lack critical knowledge to promote oral health. We recommend financial incentives for prioritizing Medicaid Early and Periodic Screening, Diagnostic, and Treatment dental services; managed care accountability; integration of medical and dental professional training, clinical care, and research; and national leadership. JAMA. 2000;284:2625-2631.

Ethics for orthodontists.

When treating children, important ethical issues may arise relating to the best interests of the child and decision making for minors. The case of a child with a cleft lip and palate whose parents failed to bring her in for medically indicated orthodontic care is presented. Ethical features of the case are discussed, including the need to benefit the patient, avoid harm, and respect the preferences of the parents. Ethical codes of the American Dental Association and American Medical Association are referenced. Ethical dilemmas include the conflict between the orthodontist's obligation to the child and the need to respect parental autonomy. Parental autonomy is respected up until the point at which significant harm to a child may result. The orthodontist's primary ethical responsibility is to the child, not the parents. The orthodontist providing medically indicated care should involve the craniofacial team or hospital social worker when parental decision making is in question.

Making decisions for children.

Making decisions for children is part of everyday orthodontic care. When conflicts arise between providers and parents, articulation of the ethical and legal principles guiding the process can be helpful. Parents are generally decision makers for their minor children, a presumption supported for practical and moral reasons and by legal precedent. The best interests of the child must guide both parents and providers. As the child matures, he or she should be brought into the decision making process as age and ability allow. A child's competency is a function of age, cognitive abilities, and personal experiences. The child should participate in the decision making process to facilitate trust, cooperation, and the development of future decisional capacities. The concepts of informed consent, parental permission, and child assent are compared and contrasted. Tables are provide that summarize these concepts and offer guidelines for providers working with children.

Controversies in the diagnosis and management of craniosynostosis: a panel discussion.

This introductory article summarizes and comments on a group of four papers based in part on a panel discussion of craniosynostosis (CS) held at the 53rd annual meeting of the American Cleft Palate-Craniofacial Association. The purpose of this panel was to review the differential diagnosis of CS and the evidence for increased intracranial pressure (ICP) and developmental problems in CS patients. First, a correct diagnosis must be made, with true synostosis being differentiated from positional deformities and other normal variants. Second, medical indications must be balanced against the risks of operating on CS patients. Release of fused sutures is commonly undertaken to avoid increased ICP, although studies of ICP in infants and children with CS are hampered by a lack of normative data and by difficulties with measurement techniques. A subgroup of children with isolated craniosynostosis may have increased ICP, which can be deleterious to brain function. Longitudinal studies of children with isolated CS suggest an increased risk of mental retardation and learning disorders; surgical release of the suture may not diminish this risk. Patients with metopic suture fusion appear to be particularly at risk. These findings must be confirmed with a larger sample size. These uncertainties raise ethical issues and complicate medical decision-making for the infant with CS. A trusting and truthful relationship between the parents and the professional is necessary for a balanced discussion of the best interests of the child. All patients with confirmed synostosis should be followed for evidence of progressive deformity, intracranial hypertension, and neurodevelopmental problems.

The differential diagnosis of abnormal head shapes: separating craniosynostosis from positional deformities and normal variants.

The correct differential diagnosis of an abnormal head shape in an infant or a child is vital to the management of this common condition. Establishing the presence of craniosynostosis, which warrants surgical correction, versus non-synostotic causes of head deformity, which do not, is not always straightforward. This paper deals with three groups of abnormal head shape that may cause diagnostic confusion: the spectrum of metopic synostosis; the dolichocephaly of prematurity versus sagittal synostosis; and the differential diagnosis of plagiocephaly. Special emphasis has been placed on the problem of posterior plagiocephaly, in the light of recent evidence demonstrating that lambdoid synostosis has been overdiagnosed. Metopic synostosis presents as a wide spectrum of severity. Although only severe forms of the disorder are corrected surgically, all cases should be monitored for evidence of developmental problems. The dolichocephalic head shape of preterm infants is non-synostotic in origin and is managed nonsurgically. The scaphocephalic head shape resulting from sagittal synostosis requires surgical intervention for correction. Posterior plagiocephaly may be due to unilambdoid synostosis or positional molding, which have very different clinical and imaging features. True lambdoid synostosis is rare. Most cases of posterior plagiocephaly are due to positional molding, which can usually be managed nonsurgically. Regardless of the suture(s) involved, all children with confirmed craniosynostosis should be monitored for increased intracranial pressure and developmental problems.

Presurgical and postsurgical mental and psychomotor development of infants with sagittal synostosis.

OBJECTIVE: The current study compared the mental and psychomotor development of infants with nonsyndromic sagittal synostosis (SS) with a demographically matched comparison group without congenital defects. Within the SS group, we tested the hypothesis that age of cranial release would be inversely correlated with mental development. DESIGN: The design was prospective and longitudinal. Participants were assessed at 4, 12, and 24 months of age. SETTING: The study was conducted in a craniofacial clinic at an urban children's hospital. PARTICIPANTS: Participants were 19 infants with SS (consecutive craniofacial program referrals) and 19 demographically matched comparison infants recruited from the community. One infant with SS did not attend the 24-month assessment. MAIN OUTCOME MEASURES: Mental and Psychomotor Indices from the Bayley Scales of Infant Development were the primary outcome measures. Subdomains of development were created using Kohen-Raz scoring procedures. All measures were determined a priori. RESULTS: Repeated-measures MANOVAs revealed no statistically significant differences in the developmental trajectories of the two groups. None of the SS group infants received Mental Development Index (MDI) scores in the mentally retarded or borderline range of intellectual functioning (i.e., below 78). An inverse correlation (r = -.30) was found between the age at surgery and Bayley growth curve coefficients; however, this association was not statistically significant (p = .10, one-tailed). CONCLUSIONS: Results are consistent with previous studies of the mental and psychomotor development of infants with nonsyndromic craniosynostoses in relation to normative test data. The relation between surgery age and developmental outcome merits further study in a larger sample with a greater range of surgery ages.

The differential diagnosis of posterior plagiocephaly: true lambdoid synostosis versus positional molding.

The diagnosis and treatment of posterior plagiocephaly is one of the most controversial aspects of craniofacial surgery. The features of true lambdoid synostosis versus those of deformational plagiocephaly secondary to positional molding are inadequately described in the literature and poorly understood. This has resulted in many infants in several craniofacial centers across the United States undergoing major intracranial procedures for non-synostotic plagiocephaly. The purpose of this study was to describe the detailed clinical, imaging, and operative features of true lambdoid synostosis and contrast them with the features of positional plagiocephaly. During a 4-year period from 1991 to 1994, 102 patients with posterior plagiocephaly were assessed in a large multidisciplinary craniofacial program. During the same period, 130 patients with craniosynostosis received surgical treatment. All patients were examined by a pediatric dysmorphologist, craniofacial surgeon, and pediatric neurosurgeon. Diagnostic imaging was performed where indicated. Patients diagnosed with lambdoid synostosis and severe and progressive positional molding underwent surgical correction using standard craniofacial techniques. Only 4 patients manifested the clinical, imaging, and operative features of unilambdoid synostosis, giving an incidence among all cases of craniosynostosis of 3.1 percent. Only 3 among the 98 patients with positional molding required surgical intervention. All the patients with unilambdoid synostosis had a thick ridge over the fused suture, identical to that found in other forms of craniosynostosis, with compensatory contralateral parietal and frontal bossing and an ipsilateral occipitomastoid bulge. The skull base had an ipsilateral inferior tilt, with a corresponding inferior and posterior displacement of the ipsilateral ear. These characteristics were completely opposite to the findings in the 98 patients who had positional molding with open lambdoid sutures and prove conclusively that true unilambdoid synostosis exists as a specific but rare entity. Awareness of the features of unilambdoid synostosis will allow more accurate diagnosis and appropriate treatment of posterior plagiocephaly in general and in particular will avoid unnecessary surgical intervention in patients with positional molding.

Who decides? Patients, parents, or gatekeepers: pediatric decisions in the craniofacial setting.

Special ethical issues arise for the craniofacial team dealing with pediatric patients, which include competency, surrogacy, and the "best interests" standard. Medical decisions for children are made by surrogates, usually parents, who must use the "best interests" standard. The team's primary responsibility is to the child, not the parents. Children should participate as abilities allow, especially for elective procedures. Increasingly, cost considerations also influence medical decisions. The craniofacial team is often a de factor gatekeeper. Ethically responsible team behavior includes: weighing risks and benefits of proposed interventions; promoting discussion with families and patients to identify "best interests;" monitoring outcomes; and advocacy for craniofacial patients individually and at a policy level. Care guidelines and definitions of basic levels of care should be developed to assist teams with decision-making and advocacy efforts. Ethical analysis is part of both good patient care and good policy formation, and should be a part of regular team deliberations.