annual report of the council on scientific affairs

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Annual Report of the Council on Scientific Affairs

Chair: Man Wai Ng Date: May 2005

Board Liaison: John R. Liu

Staff Liaison: Katherine Keating

Charge or Project Number: 1

Description: Select the recipients of the AAPD Foundation Graduate Student Research Awards, Foundation Research Awards and OMNII Post doctoral Research Fellowships for 2005-06 in accordance with AAPD policies in effect.

Status of Charge or Project: In-progress

Progress Report: 8 GSRA and 3 FRA finalists were selected by two different panels comprising of four judges each. The GSRA and FRA winners will be determined at the Annual Session in Orlando. The OMNII Fellowship recipients will be selected by the end of April and the recipients will be announced at the Annual Session in Orlando.


Description: Identify the topic, plan the program, and present the program for the Workshop on Contemporary Clinical Issues in Pediatric Dentistry held in conjunction with the 2005 Annual Session. A topic and suggested speaker(s) are to be presented for the consideration of the Scientific Program Committee at the 2004 summer planning meeting. Begin planning for the 2006 Workshop so that a topic and suggested speaker(s) may be presented for consideration of the Scientific Program Committee at the 2005 summer planning meeting.

Status of Charge or Project: In Progress

Progress Report: There will not be a 2005 Workshop due the planned abbreviated scientific program at the Annual Session in Orlando. At the CSA meeting at the 2004 Annual Session, CSA members selected obesity as the topic for the 2006 Workshop. We are actively planning the obesity workshop.


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Description: Complete required review of studies and/or scientific protocols funded by the AAPD Foundation and make recommendations for approval or revision to the appropriate committee.

Status of Charge or Project: In progress

Progress Report: We continue to stand ready to assist the AAPD Foundation Grants and Fellowships Committee.


Description: In conjunction with the Children�s Dental Health Project, select the recipient of an award that promotes and recognizes pediatric dental health services research. Develop and present to the AAPD Foundation guidelines for the selection of the nominee and the criteria by which the candidates are evaluated.

Status of Charge or Project: Postponed

Progress Report: There will not be an AAPDF HSR award recipient for 2005. In Spring 2004, guidelines developed by a CSA small workgroup were submitted to the BOT to nominate and select an annual HSR award recipient. The BOT recommended revising the guidelines to recognize an individual for a significant body of work or a lifetime of work of great significance toward the oral health of children rather than offering the HSR award as an annual competitive award for submission of research. CDH agreed with this premise. CSA will submit a revised set of HSR guidelines to the AAPDF BOT.


Description: Assist the Scientific Program Subcommittee of the Council on the Annual Session in developing scientific and education programs for the annual meeting.

Status of Charge or Project: Completed

Progress Report: Man Wai Ng represented the CSA at the Scientific Program Subcommittee planning session in Orlando in July 2004.


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Description: In conjunction with the Council on Clinical Affairs, identify the scientific basis for the policies and guidelines developed for the AAPD Reference Manual.


Progress Report: Under the exceptional leadership of Jenny Stigers, CSA members worked closely and cooperatively with CCA to provide scientific input in the development and revision of guidelines and policies. The documents are completed or close to completion.


Description: Provide recommendations to the Board of Trustees concerning the scientific validity of all communications, endorsements and publications sponsored by the Academy.


Progress Report: We stand ready to assist the BOT.


Description: At the request of the Council on Communications, review proposed pamphlets, brochures and other publications for consistency with scientific basis and accuracy.


Progress Report: We stand ready to assist the Council on Communications.


Description: Propose a mechanism and structure by which the Academy may maintain a prioritized and periodically-updated research agenda and report to the Board no later than January 2005. Begin to develop a research agenda by identifying those areas of inquiry which are the major issues and scientific challenges presently facing our specialty.



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Progress Report: Please see attached report.


Description: Identify barriers to universal acceptance of Early Infant Dental Care Visits by pediatric and general dentists.




Description: Survey the medical and dental literature to identify emerging products, practices, therapeutics, interventions, treatments, strategies, philosophies and trends applicable to pediatric oral health care. Prepare a report for the consideration of the Board of Trustees no later than May 2005. Include in that report any recommendations for actionable items.




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Appendix 1 Report on Charge 9

To: AAPD Board of Trustees From: Man Wai Ng, DDS, MPH Chair, Council on Scientific Affairs Re: Report on CSA Charge 9: AAPD Research Agenda Date: April 4, 2005 In 2004-05, the Council on Scientific Affairs was given a charge to:

Propose a mechanism and structure by which the Academy may maintain a prioritized and periodically updated research agenda and report to the Board no later than January 2005. Begin to develop a research agenda by identifying those areas of inquiry which are the major issues and scientific challenges presently facing our specialty.

Please find in the attachments (1) our report; and (2) a list of research topics that were thought to be the most pertinent to pediatric dentistry. All CSA members contributed input to this charge. Additionally, the Council of Clinical Affairs was consulted and CCA members provided input as well. CSA recommends that the AAPD BOT: 1) Review the proposed Research Agenda; 2) Approve the proposed Research Agenda along with the list of research topics of

relevance; 3) Approve having CSA re-evaluate and update the Research Agenda on an annual basis. We look forward to receiving your comments and recommendations. Respectfully submitted, Man Wai Ng


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American Academy of Pediatric Dentistry Research Agenda The American Academy of Pediatric Dentistry (AAPD) recognizes that the clinical practice of pediatric dentistry has to be driven by science and evidence-based dentistry. Where possible, our clinical practice guidelines in pediatric dentistry should be supported by the best available evidence. No longer is it acceptable for our clinical practice guidelines to be based on expert opinions. Where the evidence or science is lacking, research needs to be conducted to answer the relevant questions that arise in our clinical practice. The AAPD Research Agenda is a strategic list of scientific and clinical questions and topics that are specific to the clinical practice of pediatric dentistry. These questions will benefit from scientific review and set the agenda for the AAPD Foundation research grants. The AAPD Council on Scientific Affairs (CSA) is charged with proposing a mechanism by which the AAPD Research Agenda is to be developed and maintained. Other dental organizations have embraced evidence-based research. The National Institute of Dental and Craniofacial Research has a Strategic Plan that outlines research opportunities to support its mission to improve oral, dental and craniofacial health through research, research training, and the dissemination of health information by performing and supporting basic and clinical research. While interested in supporting clinical research, the NIDCR supports research that offers the most significant scientific promise. The American Dental Association is committed to bringing evidenced-based dentistry (EBD) concepts and practices to the dental profession. The ADA Research Agenda was developed to promote research in areas of dental practice and to designate priorities for conducting and funding evidence-based studies. The ADA Research Agenda reflects important clinical questions that are relevant to the entire profession of dentistry. Methodology, Results and Recommendations The fourteen members of the 2004-05 AAPD CSA submitted 41 research topics/questions/issues that were thought to be the most pertinent to pediatric dentistry. These topics were evaluated for duplication, consolidated and returned to the CSA members for ranking in terms of importance. After two rounds of elimination, the CSA members identified the five research topics that were deemed to be the most important for Pediatric Dentistry and would benefit the most from scientific review. These topics are listed below in descending order of priority:

1. Transmission, etiology, risk assessment, early detection, prevention and management of caries

2. Caries management using antimicrobials, fluorides, remineralizing agents 3. Disparities and barriers to accessing dental care 4. Development of a national databank on pediatric dental issues 5. Efficacy of infant oral health (i.e. first dental visit by age one)

Additional topics of relevance are as follows:


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6. Pulp biology and efficacious and biocompatible pulp treatment 7. Safe and effective sedative agents for pain and anxiety control 8. Specific (immunity) and non-specific host factors in the etiology and prevention of

dental caries 9. Interface between medicine and dentistry in addressing access to care 10. Biologic and behavioral factors in the natural history of caries 11. Parenting styles 12. Non-pharmacologic behavior management approaches 13. Efficacy and biocompatibility of restorative materials 14. Pediatric dentist’s role in monitoring, preventing and managing obesity 15. Etiology, detection, prevention and management of pre-pubertal and juvenile

periodontal disease As to be expected from a group of individuals who practice in different regions of the United States and who possess a wide array of scientific expertise and interests, CSA members did not share a consensus in terms of how the research topics ought to be ranked. Nevertheless, the �top five� topics received composite ranking scores that were significantly higher than the rest and they were ranked more frequently (see attached complete list of topics and summary of rankings). Some CSA members found it difficult to rank the research topics. Some members felt that the AAPD Research Agenda should reflect the unique aspects of pediatric dentistry practice that have limited appeal to other dental disciplines. Others felt that while some topics have been left off the �top ten,� they are important to include in the overall Research Agenda. As such, the attachment is a list of all topics that CSA members felt to be important. The Council of Clinical Affairs was consulted. The Caries Risk Assessment Tool (CAT) was specifically recommended to be included in the list of research topics of relevance. Although CAT could be included under the broad topic of �Transmission, etiology, risk assessment, early detection, prevention and management of caries,� it was singled out as needing research. The CSA recommends that our council re-evaluate and update the AAPD Research Agenda on an annual basis. We invite input from the AAPD Board of Trustees and the AAPD Foundation.

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To: AAPD Board of Trustees From: Man Wai Ng, DDS, MPH Chair, Council on Scientific Affairs Re: Report on Charge 10: Early Infant Dental Care Visits Date: April 10, 2005 In 2004-05, the Council on Scientific Affairs was given a charge to:

Identify barriers to universal acceptance of Early Infant Dental Care Visits by pediatric and general dentists. This charge is a tactic to meet strategy 1.1.1 Background and Intent: The Academy has identified universal acceptance of anticipatory guidance and preventive dental care in a dental home beginning at age one as a strategic priority. The Board desires specific information on the barriers to implementation of this policy by private practitioners. Consider a survey instrument or �focus group� collection of data.

Please find in the attachments (1) a statement with recommendations from the Infant Oral Health workgroup; (2) a literature review on the �Age One Dental Visit,� from a CSA workgroup led by Robert Frank and also included Jessica Lee and Tegwyn Hughes. Their work represents an outstanding effort to summarize what is available in the literature on Infant Oral Health and the Age One Dental Visit. In the workgroup�s extensive review of the available literature, they found limited documentation on the barriers to the age one dental visit by general or pediatric dental providers. That is, there is not evidence that the concept of the age one dental visit is not reasonable and justified, but as of yet, unstudied and undocumented. At the same time, they found limited evidence about the effectiveness of the age one dental visit and anticipatory guidance. From the Infant Oral Health workgroup�s excellent report, CSA respectfully submits to the AAPD BOT the following recommendations: The AAPD should:

1. Introduce an AAPD taskforce composing of individuals with research expertise in early childhood caries (ECC) to examine the critical issues and make research recommendations.

2. Develop research strategies to determine what forms of information dissemination will result, if at all, in the most effective reduction of ECC.


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3. Promote research to identify children susceptible to ECC and see how they differ from non-susceptible children.

4. Promote research to study the effectiveness of Early Infant Dental Care (first dental visit by age one).

5. Support evidence based research (focus groups, surveys, population-based studies) to explore the reasons for which pediatric dentists and general dentists have not fully embraced universal acceptance of Early Infant Dental Care Visits (first dental visit by age one).

We look forward to receiving your comments and recommendations. Respectfully submitted, Man Wai Ng


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To: Man Wai Ng, DDS, MPH Chair, Council on Scientific Affairs From: Robert Frank, DMD Jessica Lee, DDS Tegwyn Hughes, DDS Re: CSA Charge 10

Identify barriers to universal acceptance of Early Infant Dental Care Visits by pediatric and general dentists. This charge is a tactic to meet strategy 1.1.1 Background and Intent: The Academy has identified universal acceptance of anticipatory guidance and preventive dental care in a dental home beginning at age one as a strategic priority. The Board desires specific information on the barriers to implementation of this policy by private practitioners. Consider a survey instrument or �focus group� collection of data.

Attachment: 1) Age One Dental Visit�Literature Review A fairly extensive literature review has yielded no evidence that having a child seen by a dentist around his or her first birthday will reduce incidence of early childhood caries. However, there is no evidence that it won�t. There are studies that show recurrence of decay in children and their siblings afflicted with early childhood caries is very common. This occurs in spite of treatment and education. 1,2,3,4,5,6

From the evidence available, access to information about dental disease should be made available at any age and perhaps earlier than one. It needs to be determined how best to do that. Evidence is available that shows motivated caretakers have the ability to reduce the incidence of decay in low socio-economic families.7,8,9 Can we motivate more caretakers and what is the best method for doing this? Finding ways to identify children most susceptible to early childhood caries and concentrating on dental visits by those children may be more effective than having all children seen by a dentist at a very early age. Can the use of allied health providers be effective? There are studies that show parents and health professionals can be taught to recognize dental disease.10 Investigating the utilization and development of chemo-therapeutic agents in preventing and /or altering the course of the disease are also apparent from our search of the literature.11

There is no documentation on the barriers to the age one dental visit by general or pediatric dental practitioners. There is limited evidence about the effectiveness of the age one dental visit and anticipatory guidance. The lack of infant oral health training for dental providers in addition to the lack of evidence on the effectiveness of the age one dental visit may be barriers to adoption of the age one dental visit in practice. Addressing the implementation of the �age one dental visit� will involve a modification in dental education, the removal of barriers in accessing dental care, and the coordination of both private and public health care.


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We feel the Academy and its allied health professionals must help in gathering information needed to base its policies for eliminating early childhood caries on scientific evidence. We can only answer the question of whether to maintain the current policy or alter it by gathering more information. Funding research in prevention and treatment leading to the elimination of early childhood caries, finding ways to increase access to care for children, and dissemination of information should be among the primary goals of the AAPD.

RECOMMENDATIONS: The AAPD should:

6. Introduce an AAPD taskforce composing of individuals with research expertise in early

childhood caries (ECC) to examine the critical issues and make research recommendations.

7. Develop research strategies to determine what forms of information dissemination will result, if at all, in the most effective reduction of ECC.

8. Promote research to identify children susceptible to ECC and see how they differ from non-susceptible children.

9. Promote research to study the effectiveness of Early Infant Dental Care (first dental visit by age one).

10. Support evidence based research (focus groups, surveys, population-based studies) to explore the reasons for which pediatric dentists and general dentists have not fully embraced universal acceptance of Early Infant Dental Care Visits (first dental visit by age one).


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AGE ONE DENTAL VISIT The American Academy of Pediatric Dentistry (AAPD) and the American Dental

Association (ADA) recommend that the first dental visit be no later than 12 months of age.1 The stated goal of the infant dental visit is to make an assessment of the child�s risk for caries and to provide anticipatory guidance for the parent/caregiver to include oral hygiene and home care counseling, fluoride and dietary analysis, and other recommendations that may be pertinent to the specific child and family.1 Like well-child medical visits, one of the most important dimensions of the infant dental visit is to prepare parents for future dental milestones and age-specific needs. The dental profession embraces the concept that with early intervention, it may be possible to reduce or eliminate future oral disease.2

Anticipatory guidance is the process of providing practical, developmentally

appropriate information about children�s health to prepare parents for the significant physical, emotional, and psychological milestones.3 The concept of anticipatory guidance emanates from the medical model and it is well-accepted among physicians that using anticipatory guidance during well-child visits is an effective tool to educate parents about what can be done to maintain children�s health. Using the medical model, the AAPD has operationalized the concept of anticipatory guidance to include parent�s/caregiver�s guidance in infant oral hygiene, home and office-based fluoride therapies, dietary counseling, and information relative to oral habits and dental injury prevention.1, 4

The use of anticipatory guidance and well-child visits during the first two years of life has been shown to decrease the number of hospitalizations among poor and near-poor children irrespective of race and health status.5 RATIONALE In theory early dental visits may reduce the child�s future dental risk leading to improved oral health and reduced oral health costs. Because untreated dental disease increases in severity and necessitates more extensive and costly treatment secondary to postponing care, timely intervention has the potential to reduce overall costs associated with dental treatment in preschool children. For example, Iowa Medicaid children less than age six treated for ECC in the hospital or ambulatory care setting represented less than 5% of those receiving dental care but consumed 25% to 45% of the dental resources.6 The total cost to the Iowa Medicaid program for hospital-based general anesthesia was over $2000 per child in this investigation.6 A similar study from Washington state concluded that 19% of their pediatric dental emergencies were related to ECC and of those over half were children 3.5 years or younger.7 These studies point out that early prevention can translate into significant cost-savings for dental care, especially for those families at or below the poverty level where caries rates are dramatically higher in children three years old and under. To date, there is a paucity of evidence about the age one dental visit. Savage and colleagues8 concluded that preschool Medicaid children who had an early preventive dental visit were more likely to use preventive services in the future and that children who utilized early preventive services had less dentally-related costs compared to those who began preventive services at a later time. In addition there is little documentation on the barriers to the age one dental visit. According to the AAPD nearly 20% of pediatric dentists do not perform infant evaluations.9 There are varying degrees


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of acceptance in teaching infant oral health in dental schools. The average dental school curricula spends 2 hours on infant oral health and only 50% of dental schools provide any clinical experience treating the infant population.10 A study by Cotton et al., showed that as the patient age decreased fewer general dentists were willing to provide treatment in addition to the fact that the level of training received in dental school was significantly associated with their attitude to treating infants.11 SUMMARY

A fairly extensive literature review has yielded no evidence that having a child seen by a dentist around his or her first birthday will reduce incidence of early childhood caries. However, there is not evidence that the concept of the age one dental visit is not reasonable and justified, but as of yet unstudied and undocumented. From the evidence available, access to information about dental disease should be made available at an early age, specifically prior to age three. Evidence is available that shows motivated caretakers have the ability to reduce the incidence of decay in low socio-economic families.8,12,13 Addressing the implementation of the �age one dental visit� will involve a modification in dental education, the removal of barriers in accessing dental care, and the coordination of both private and public health care. Finding ways to identify children most susceptible to early childhood caries and concentrating on dental visits by those children may be more effective than having all children seen by a dentist at a very early age.

There is no documentation on the barriers to the age one dental visit by general or pediatric dental practitioners. There is limited evidence about the effectiveness of the age one dental visit and anticipatory guidance. The lack of infant oral health training for dental provider in addition to the lack of evidence on the effectiveness of the age one dental visit may be barriers to adoption of the age one dental visit in practice. Even with this lack of evidence, the rationale of anticipatory guidance for getting children to the dentist early with age three being too late holds true. The Academy and oral health professionals must help in gathering the evidence based research (focus groups, surveys, population-based studies) needed to base its policies for establishing an age one dental visit on scientific evidence. The following recommendations have been made. RECOMMENDATIONS

1. Develop research strategies to determine what forms of information dissemination will result in the most effective reduction of ECC.

2. Develop research strategies to identify the barriers to early infant dental visits. 3. Develop research strategies to examine the effectiveness of early infant dental visits. 4. Develop research strategies to identify populations of high-risk children who would

benefit from an age one dental visit. LITERATURE CITED 1. Infant Oral Health. Journal of the American Academy of Pediatric Dentistry

2000;22(7):82.


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2. Sanchez OM, Childers NK. Anticipatory guidance in infant oral health: rationale and

recommendations. [see comments]. American Family Physician 2000;61(1):115-20. 3. Nowak AJ, Casamassimo PS. Using anticipatory guidance to provide early dental

intervention. JADA 1995;126(8):1156-63. 4. Nowak AJ, Warren JJ. Infant oral health and oral habits. Pediatr Clin of North America

2000;47(5):1043-66. 5. Hakim RB, Bye BV. Effectiveness of compliance with pediatric preventive care

guidelines among Medicaid beneficiaries. Pediatrics 2001;108(1):90-7.

6. Kanellis MJ, Damiano PC, Momany ET. Medicaid costs associated with the hospitalization of young children for restorative dental treatment under general anesthesia. J of Public Health Dent. 2000;60(1):28-32.

7. Sheller B, Williams BJ, Lombardi SM. Diagnosis and treatment of dental caries-related emergencies in a children's hospital. Pediatr Dent. 1997;19(8):470-475.

8. Savage MF, Lee JY, Kotch JB, Vann WF jr. Early Preventive Dental Visits: Effects of Subsequent

Use and Costs. Pediatrics 2004 114;419-423. 9. Erikson P, Thomas H. A Survey of the American Academy of Pediatric Dentistry

Membership: Infant Oral Health Care. Pediatric Dentistry 1997; 19: 17-21. 10. Cotton K, Seale S, Kanellis M, Damiano P. Are general dentists practice patterns

and attitudes about treating Medicaid enrolled preschool age children related to dental school training. Pediatric Dentistry. 23:1, 2001.

11. McWhorter AG, Seale NS, King SA. Infant oral health education in U.S dental

school curricula. Pediatr Dent 23: 407-409, 2001. 12. Gomez SS, Weber AA. Effectiveness of a caries preventive program in pregnant

women and new mother on their offspring. 13. Lee C, Rezaiamira N, Jeffcott E, Oberg D. Domoto P, Weinstein P. Teaching Parents at WIC clinics to examine their high caries-risk babies. ASDC J Dent Child. 1994 Sep-Dec:61(5-6):347-9


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LITERATURE CITED: 1. Primosch RE, Balsewich CM, Thomas CW. Outcomes assessment an intervention

strategy to improve parental compliance to follow-up evaluations after treatment of early childhood caries using general anesthesia in a Medicaid population. ASDC J Dent Child. 2001 Mar-Apr;68(2):102-8

2. Almeida AG, Roseman MM, Sheff M, et.al. Future caries susceptibility in children with

early childhood caries following treatment under general anesthesia. Pediatric Dent. 2000 Jul-Aug;22(4):302-6

3. Chase, I, Berkowitz RJ, Proskin HM, Weinstein P, Billings R. Clinical outcomes

For Early Childhood Caries (ECC): the influence of health locus of control. Eur J Paediatr Dent. 2004 Jun;5(2):76-80

4. Graves CE, Berkowitz RJ, Proskin HM, Chase I, Weinstein P, Billings R. Clinical outcomes for early childhood caries: influence of aggressive dental surgery. J Dent Children 2004 May-Aug;71(2):114-7

5. Huntington NL, Kim IJ, Huges CV. Caries-risk factors for Hispanic children

affected by early childhood caries. Pediatr Dent. 2002 Nov-Dec;24(6):536-42

6. Tinanoff N, Daley NS, O�Sullivan DM, Douglass JM. Failure of intense preventive efforts to arrest early childhood and rampant caries. three case reports.

7. Savage MF, Lee JY, Kotch JB, Vann, WF. Pediatrics 2004;114:418-423 8. Gomez SS, Weber AA. Effectiveness of a caries preventive program in pregnant

women and new mother on their offspring. 9. Lee C, Rezaiamira N, Jeffcott E, Oberg D. Domoto P, Weinstein P. Teaching Parents at WIC clinics to examine their high caries-risk babies. ASDC J Dent Child. 1994 Sep-Dec:61(5-6):347-9 10. Rozier G, Sutton BK, Bawden JW, Haupt, Slade GD, King RSl Prevention of Early childhood caries in North Carolina medical practices: implications for Research and practicel J Dent Educ. 2003 Aug:67(8):876-85 11. Marinho, VCC, Higgins, JPT, Logan, S, Sheiham, A. Fluoride varnishes for Preventing dental caries in children and adolescents. Chochrane Database of Systematic Reviews.4, 2004


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To: AAPD Board of Trustees

From: Man Wai Ng, DDS, MPH

Chair, Council on Scientific Affairs

Re: Report on Charge 11: Emerging products, practices, etc. applicable to pediatric oral health care

Date: April 8, 2005

In 2004-05, the Council on Scientific Affairs was given a charge to:

Survey the medical and dental literature to identify emerging products, products, therapeutics, interventions, treatments, strategies, philosophies and trends applicable to pediatric oral health care. Prepare a report for the consideration of the Board of Trustees no later than May 2005. Include in that report any recommendations for actionable items. This charge is a tactic to meet strategy 3.2.2. Background and Intent: This charge results from a recommendation of the January 2004 Planning Session that the Academy take the initiative in anticipating changes in clinical practice, including �off-label� use of pharmaceuticals and advances in diagnostic technology.

Please find in the attachments (1) an excellent report prepared by Jan Hu and edited by Kevin Donly and (2) two addenda prepared by Man Wai Ng. Jan�s report focuses specifically on diagnostic tools for caries and periodontal disease assessment and preventive measures for these diseases. Man Wai�s addenda to the report focus on emerging trends in orthodontics and endodontics that may be of relevance t to the practice of pediatric dentistry. As this charge was broad and open-ended, the authors attempted to perform and summarize literature searches on those areas and trends thought to be applicable to pediatric oral health. This report is not intended to be all-inclusive. We have included accepted practices in orthodontics and endodontics that have crossed-over applications to pediatric dentistry and which may alter pediatric dental clinical practice. We are pleased to point out that the many of the emerging trends summarized in this report, especially in risk assessment, caries diagnosis and prevention, have been identified by the CSA to be areas of research of clinical importance to pediatric dentistry (Charge 9 Research Agenda). We expect that new trends will emerge at an increasingly rapid rate in years to come that will continue to improve the clinical practice of pediatric dentistry. We look forward to receiving your comments and recommendations. Respectfully submitted, Man Wai Ng


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AAPD COUNCIL ON SCIENTIFIC AFFAIRS charge #11 Survey the medical and dental literature to identify emerging products, practices, therapeutics, interventions, treatments, strategies, philosophies and trends applicable to pediatric oral health care. This report was prepared by Jan Hu and edited by Kevin Donly Introduction Purpose of this report is to provide a literature review of diagnostic tools and caries preventive measures pertinent to the practice of pediatric dentistry. PubMed was used for literature search. Scientific reports pertinent to this review are listed under �References�. Diagnostic Tools

• Caries Risk Assessment • Periodontal Disease Susceptibility • Caries Detection Devices

Caries Risk Assessment Conventional assessment tools have a fundamental working mechanism based on detection of bacterial enzyme activities or acid-production potential of the test individual�s biofilm or saliva. The Dentocult SM Strip mutans test (D-SM, Vivadent) is a popular method for estimating salivary mutans streptococci and is clinically used for the detection of potential caries risk patients. The efficiency of MS detection improved significantly by increasing the number of sites used for MS estimates [Seki et al., 2002]. When comparing sensitivity, accuracy, and kappa values, the site strip plaque test surpassed the salivary chair-side test [Karjalainen et al., 2004]. Developed by Dr. Shimono�s group at Okayama University Dental School, Cariostat caries activity test is a product designed to measure the pH decrease caused by microorganisms in the plaque sample obtained from the buccal surfaces of teeth. Since the sampling method is non-invasive and analysis time is short, Cariostat is considered a useful screening tool for identifying toddlers most likely to develop decay and it can be used periodically to monitor bacterial colonization and assess caries risk [Nishimura et al., 1998]. The Clinpro Cario L-Pop lactic acid indicator biochemical test is said to easily and quickly diagnose the caries potential of patients, even if dental defects are not visible. Combining biochemical knowledge and enzyme technology, the test allows users to detect caries early and start suitable diagnostic and preventive measures. A saliva sample is taken from the tongue with a lactic acid indicator swab, and the swab is then placed into a blister wherein an enzymatic chain reaction takes place within two minutes. The test swab reacts with a color change, which serves as an indicator for the existing caries potential. A nine-stepped color code helps determine test results and levels of caries potential. This product is developed by 3M ESPE AG, Germany, For more information, please consult <http//:www.3mespe.com>. The DNAStrip Technology--BuffCheck®test-caries risk, CarioCheck®-plus-Caries risk, CarioCheck®-plus SM/LB, and CarioCheck®-plus starter kit are developed and marketed by


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Hain Lifescience GmbH in Nehren. The working mechanism of these products is based on hybridization of DNA probes made from known cariogenic bacteria strains and host plaque sample. An incubation oven TwinCubator® with hybridization block to process the sample strips is necessary. The test sensitivity and specificity remain to be determined. No literature was found in PubMed reporting outcome assessment of these products at this time. Determination of Periodontal Disease Susceptibility Bystanders commonly label dentistry as a profession devoting all efforts in treating consequences of the disease instead of curing and preventing the disease. Since early 2004, we have witnessed a trend transforming the profession and very likely shaping the future of dental practice facilitated by the advance in genomic and proteomic technologies. It won�t be long before the dentist can make a chair side determination of oral flora composition, salivary fluid characteristics, and susceptibility to periodontal diseases, caries, etc. of his/her patient using a hand held device driven by computer chips orchestrating a mini protein and DNA laboratory within the device. The development of highly specific and sensitive antibodies that detect antigens present at a trace amount allows an accurate identification of bacteria species and determination of their quantity within a few minutes. The characterization of positive association between single nucleotide polymorphisms (SNPs) and specific type of periodontal disease forms the working mechanism of DNA strips for determination of periodontal disease susceptibility. Dental researchers are teaming up with bioengineers in the construction of diagnostic device that�s designed to provide rapid and accurate analysis at the chair side. A few products are available in the market although their efficacy remains to be determined. Target Pathogen Analysis with micro-dent and micro-Ident plus. Developed by Hain Lifescience GmbH <www.hain-lifescience.com > centered on the DNA Strip® technology, these products are to provide the following benefits.

• Adjustment of the use of supportive antibiotics • Risk classification of periodontal sites • Monitoring response to therapy • Determination of individual recall intervals.

Products

1. Fungi-dent® color-candida 2. GenoType® PST®--Description Molecular genetic assay for combined detection of

the IL-1A -889 und IL-1B +3953 polymorphisms of the interleukin-1 gene cluster. 3. Micro-IDent®----micro-IDent®Molecular genetic assay for combined analysis of 5

periodontal pathogens. 4. Micro-IDent® plus--Molecular genetic assay for combined analysis of 6 additional

periodontal pathogens. 5. Micro-IDent® sampling point sets 6. PST® sampling point sets


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Hardware requirement--The TwinCubator®: a thermo shaker. Preliminary Testing of Periodontal and Cardiovascular Disease Biomarkers Using New Saliva Kit--under development at the University of Michigan. Please consult <http://www.dent.umich.edu/about/aboutschool/news/news2005/news022205.html> The hand-held, battery-powered rapid-test kit is being used to test saliva samples from several dozen patients to determine if they have periodontal or cardiovascular disease biomarkers. Once marketed, the kit will allow dentists to test patients in their offices and learn, in 15 minutes or less, if their patients have those diseases. One day the kit may also be used by federal, state, or local government agencies as well as corporations to detect biological toxins. Please note that literature report of these newest disease susceptibility assessment tools is not available at this time. Caries Detection Devices The reduction in smooth surface caries has resulted in an increase in the proportion of small lesions in the pits and fissures of teeth [McComb and Tam, 2001]. The diagnosis of pit and fissure caries continues to be a dilemma for clinicians. The use of lasers for dental diagnostics is considered to be promising, mainly through the phenomenon of laser-induced fluorescence (or luminescence) of the enamel. A major reference used in this section is a publication of Dr. Joel Berg in 2004 (reference #8). DIAGNODent or DD (KaVo America, Lake Zurich, Ill.) is a caries-detection tool that has been in the US market for many years. The device uses a laser light to fluoresce the enamel and determine the level of demineralization based on the emitted fluorescent frequency. It is considered a useful adjunct detection device when combined with conventional visual or radiographic examination [Berg, 2004]. Reis et al. [2004] reported that in a low (caries) prevalence sample, the visual inspection provided the highest proportion of true disease identified correctly, and DIAGNODent provided the highest proportion of non-disease identified correctly. The device was tested to be effective in detection of the extension of demineralization of non-cavitated smooth-surface caries lesions in primary teeth [Mendes et al., 2004]. Following a thorough review, Bader and Shugars [2004] stated that DIAGNODent is more sensitive than traditional diagnostic methods; however, the increased likelihood of false-positive diagnoses compared with that with visual methods limits its usefulness as a principal diagnostic tool. DIFOTI uses fiber-optic transillumination to quantify mineral loss of enamel. A high-intensity white light is transmitted through the tooth, and an image is collected by a digital camera and projected onto a computer screen. The intense visible light scatters differentially when encountered structures with various degrees of mineralization. When combined with digital imaging, this device has a sensitivity close to radiological imaging [Schneiderman et al., 1997]. Although the device has been improved and is thought to be potentially more sensitive than conventional radiography.


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Quantitative laser-induced fluorescence (QLF I) as well as the quantitative light-induced fluorescence (QLF II) seem promising for the quantification of mineral loss from dental caries in both the permanent and primary teeth [Ando et al., 2001]. The device uses fluorescent light to scan the surface enamel and analyze the degree of mineralization. Applying QLF longitudinal measures can be made on the same surface, and examples of its use are for monitoring recurrent caries and demineralization around orthodontic brackets [Higham et al., 2005]. Eggertsson et al. [1999] evaluated the uses of laser fluorescence and dye-enhanced laser fluorescence (DELF), compared them to visual examination and found DELF was better in sensitivity, but DELF and visual examination were better than laser fluorescence in specificity. A study by Alwas-Danowska et al., [2002] concluded that using dc luminescence was not statistically significantly different from visual inspection and the equipment is suitable for detecting small superficial lesions, rather then deep dentinal lesions. There are various sensitivity and specificity values obtained for the DIAGNODent and they differ widely among different reports [Alwas-Danowska et al., 2002; Henrich-Weltzien et al., 2002; Anttonen et al., 2003]. Non-intrusive, non-contacting frequency-domain photothermal radiometry (FD-PTR or PTR) and frequency-domain luminescence (FD-LUM or LUM) have been used with 659- and 830-nm laser sources to assess the pits and fissures on the occlusal surfaces of human teeth. Fifty-two human teeth were examined with simultaneous measurements of PTR and LUM and were compared to conventional diagnostic methods including continuous (dc) luminescence (DIAGNODent), visual inspection and radiographs. PTR and LUM, as a combined technique, has the potential to be a reliable tool to diagnose early pit and fissure caries and could provide detailed information about deep lesions. Using the longer wavelength (830-nm) laser source, it has been shown that detection of deeper subsurface lesions than the 659-nm probe provides is possible [Jeon et al., 2004]. The technique is based on the modulated thermal infrared (black-body or Planck radiation) response of a medium, resulting from radiation absorption and non-radiative energy conversion followed by temperature rise (in the case of dental interrogation, less than 1 ° C). The generated signals carry subsurface information in the form of a temperature depth integral. Thus, PTR has the ability to penetrate, and yield information about, an opaque medium well beyond the range of optical imaging. A combination of FD-PTR and FD-LUM was used as a fast dental diagnostic tool to quantify sound enamel or dentin as well as subsurface cracks in human teeth [Jeon et al., 2004]. The first attempt to apply the depth profilometric capability of frequency-domain laser infrared photothermal radiometry (PTR) toward the inspection of dental defects was recently reviewed by Nicolaides et al. [2002]. The approach consists of a combined dynamic (i.e. non-static, steady-state signal level) dental depth profilometric inspection technique, which can provide simultaneous measurements of intensity-modulated frequency-domain PTR (FD-PTR) and luminescence (FD-LUM) signals from defects in teeth. FD-PTR is an evolving technology and has been applied, among other areas, to the non-destructive evaluation of subsurface features in opaque materials [Busse and Walther, 1992].


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Preventive Measures Many agents have been shown to have an anticaries effect or to have the potential for such an effect. They can be categorized by their modes of action into three groups: those, which affect plaque and plaque bacteria, those which affect tooth enamel chemistry and those which buffer oral pH. To be effective clinically, agents must not only possess intrinsic efficacy but also good oral retention characteristics [Duckworth RM, 1993]. Three chemicals and their cariostatic effect were reviewed.

1. Xylitol products 2. Chlohexidine products 3. Fluoride

Xylitol The most widely used sugar alcohols are: xylitol, sorbitol, mannitol, maltitol, lactitol and the products Lycasin and Palatinit. It is often claimed that xylitol is superior to the other sugar alcohols for caries control. The caries-preventive effects of polyol-containing gums and candies seem to be based on stimulation of the salivary flow, although an antimicrobial effect cannot be excluded. There is no evidence for a caries-therapeutic effect of xylitol [Loveren 2004]. Twetman and Stecksen-Blicks reported in 2003 that a 14-day use of xylitol-containing chewing gums, corresponding to a daily amount of 5 grams of xylitol, could diminish glucose-initiated lactic acid formation in supragingival plaque in caries-active pre-school children. Sengun et al., 2004 concluded that the use of a xylitol lozenge after a sucrose challenge can be an advisable practice for fixed orthodontic patients to prevent future dental caries. Chlohexidine Baca et al. [2004] investigated the effect of chlorhexidine-thymol varnish on the prevention of caries lesions in primary molars among schoolchildren ages 6 to 7 in relation to their previous experience with caries. The varnish was applied once in three months for a period of 24 months. It was concluded that chlorhexidine-thymol varnish reduces caries lesions in the primary molars of schoolchildren ages 6 to 7 with no previous caries lesion experience. A well-controlled study was conducted to investigate the influence of an amine fluoride/stannous fluoride (Meridol, 250 ppm; ASF) and a chlorhexidine mouthrinse (CHX; Chlorhexamed forte, 0.2%) compared with water on in situ biofilm growth. Both mouthrinse showed antibacterial and plaque-reducing properties against the in situ biofilm on human subjects [Auschill et al., 2005]. The anti-microbial effect of CHX mouth-rinse varies according to its preparation and the presence of other active ingredients. A recent study compared 5 commercially available CHX-containing mouth rinse and concluded that CHX when combined with 0.05% cetylpiridinium chloride demonstrated a significant anti-halitosis effect and anti-microbial activity in saliva [Roldan et al., 2005]. Oral malodour (halitosis) is generally ascribable to oral microbial putrefaction generating malodorous volatile sulphur compounds which predominantly comprise dihydrogen sulphide


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and methyl mercaptan. White and Armaleh (2004) compared the effect of tongue scraping, Listerine Oral Care Strip, and saline rinse prior to brushing in reducing halitosis and concluded that tongue scraping is the most effective method among the three. Chlorhexidine demonstrated statistically significant reductions that ranged from 81-90% for tongue microflora with a 89-95% decrease noted on salivary flora (p<0.05). The effects of CHX on anaerobic, Gram-positive and Gram-negative bacteria are in accord with those noted on odorigenic bacteria producing H2S or proteolytic activity [Sreenivasan and Gittins, 2004]. Although the effect of CHX in Mutans streptococci reduction is well-established, the negative taste sensation associated with high concentration of CHX is a concern in general and especially in pediatric population [Pienihakkinen et al., 1995]. Fluoride The most extensively clinically-proven anti-caries agent is fluoride. The fluoride mouth rinse duration has been investigated recently. It is reported by Adachi et al. [2005] that the average total fluoride retained in the mouth was 0.13 mg after 20 s and 0.17 mg after 30 s rinse. There�s no significant difference between those two time points. Therefore, fluoride mouth rinse time for school age children can be decreased from 30 s to 20s. Wyatt and MacEntee [2004] reported a study on the effectiveness of either a 0.2% neutral sodium fluoride (NaF) solution or a 0.12% chlorhexidine (CHX) solution as a daily mouthrinse for controlling caries. The mouthrinse was tested against a placebo rinse in this 2-year randomized clinical trial among elders in long-term care (LTC) facilities. It was concluded that 0.2% neutral NaF mouthrinse every day does reduce the incidence of caries. A recent study conducted by Pizzo et al. [2004] aimed at searching for alternative mouth rinses to replace CHX compared plaque inhibitory effect of CHX, amine fluoride/stannous fluoride (ASF) and antimicrobial host proteins (lactoperoxidase, lysozyme and lactoferrin; LLL). The results indicated that the ASF rinse may represent an effective alternative to CHX rinse as an adjunct to oral hygiene. On the contrary, the LLL rinse did not significantly inhibit plaque regrowth. Fluoride concentration following rinse or varnish application was determined in a recent study [Eakle et al., 2004] which was a two-period, two-treatment randomized cross-over experimental trial with a 2-week washout period was used with 16 adult subjects. In the first period, eight subjects rinsed once with a 0.05% NaF solution and 8 subjects had 5.0% NaF varnish applied to facial and lingual surfaces of 20 teeth. Stimulated whole saliva was collected at baseline, 5 and 15 min, 1, 2, 4, 8, 12, 24, 32, 48, 56, 72, 80, 96, 104 h. Salivary fluoride levels with the rinse returned to baseline, on average, in 2 h while they remained elevated for, on average, 24 h with the varnish. Salivary fluoride levels from the varnish were found to be comparable with those in previous studies for 1.1% neutral NaF. Fluoride concentrations in saliva after chewing a F containing chewing gum had only small numerical differences among the various chewing times, with the exception for 5 min. All chewing time periods showed statistically significant differences between chewing and non-chewing side. (2) The prolonged chewing time increased the plaque pH recovery after a sucrose rinse (p<0.05) but there was no statistically significant difference on both of the chewing and


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non-chewing side (p>0.05). The results of this study indicated that a prolonged chewing time was favorable to the plaque pH recovery after a sucrose rinse and, to a certain extent, to the salivary fluoride concentration. Also it was shown that the F concentration in saliva was strongly dependent on which side the subject chewed on. A randomized clinical trial was performed to test the efficacy of a fluoridated hydrogen peroxide-based mouthrinse on gingivitis and tooth whitening in a two-phase study. The results of this study indicate that the fluoridated hydrogen peroxide-based mouthrinse effectively whitens teeth and significantly reduces gingivitis [Hasturk et al., 2004]. A novel preparation of fluoride mouthrinse with a small component of essential oil is under testing for its anitmicrobial effects [Zhang et al., 2005]. A clinical study conducted at Pfizer evaluated the effect of rinsing with an essential oil-containing antiseptic mouthrinse, with or without 100 mg/kg fluoride ion, on the plaque metabolic acid production and plaque pH response after a sucrose challenge. This observer-blind, randomized study used a three-way crossover design. The authors concluded that this EO antiseptic mouthrinse, with or without fluoride ion, is effective in reduction of plaque acidogenicity after a sucrose challenge.


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References 1. Adachi K, Nakagaki H, Tsuboi S, Maruyama S, Goshima M, Shibata T, Mukai M,

Robinson C, Mariano RB. (2005) Intra-oral fluoride retention 3 minutes after fluoride mouthrinsing in 4- to 5-year-old children: effects of fluoride concentration and rinsing time. Caries Res. 2005 Jan-Feb;39(1):48-51.

2. Alwas-Danowska HM, Plasschaert AJM, Suliborski S, Verdonschot EH: (2002) Reliability

and validity issues of laser fl uorescence measurements in occlusal caries diagnosis. 30:129�134.

3. Ando M, van Der Veen MH, Schemehorn BR, Stookey GK. (2001) Comparative study to

quantify demineralized enamel in deciduous and permanent teeth using laser- and light-induced fluorescence techniques. Caries Res. 35(6):464-70.

4. Anttonen V, Seppä L, Hausen H (2003) Clinical study of the use of the laser fluorescence

device DIAGNOdent for detection of occlusal caries in children. Caries Res 37: 17�23. 5. Auschill TM, Hein N, Hellwig E, Follo M, Sculean A, Arweiler NB (2005): Effect of two

antimicrobial agents on early in situ biofilm formation. J Clin Periodontol 32: 147-152. 6. Baca P, Munoz MJ, Bravo M, Junco P, Baca AP. (2004) Effectiveness of chlorhexidine-

thymol varnish in preventing caries lesions in primary molars. J Dent Child (Chic). 71(1):61-5.

7. Bader JD, Shugars DA. (2004) A systematic review of the performance of a laser

fluorescence device for detecting caries. J Am Dent Assoc. 135(10):1413-26. 8. Berg JH (2004) New technologies in pediatric dentistry: dental caries detection and caries

management by risk assessment. Essence 2(1): 3-6. 9. Busse G, Walther HG (1992): Photothermal nondestructive evaluation of materials with

thermal waves; in Mandelis A (ed): Principles and Perspectives of Photothermal and Photoacoustic Phenomena. Elsevier, New York, 1992, vol 1, pp 205�298.

10. Duckworth RM. (1993) The science behind caries prevention. Int Dent J. 43(6 Suppl 1):529-

39. 11. Eakle WS, Featherstone JD, Weintraub JA, Shain SG, Gansky SA. (2004) Salivary fluoride

levels following application of fluoride varnish or fluoride rinse. Community Dent Oral Epidemiol. 2004 Dec;32(6):462-9.

12. Eggertsson H, Analoui M, van der Veen M, Gonzalez-Cabezas C, Eckert G, Stookey G.

(1999) Detection of early interproximal caries in vitro using laser fluorescence, dye-enhanced laser fluorescence and direct visual examination. Caries Res. 1999 May-Jun;33(3):227-33.


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13. Eldridge KR, Finnie SF, Stephens JA, Mauad AM, Munoz CA, Kettering JD. (1998) Efficacy

of an alcohol-free chlorhexidine mouthrinse as an antimicrobial agent. J Prosthet Dent. 80(6):685-90.

14. Hasturk H, Nunn M, Warbington M, Van Dyke TE. (2004) Efficacy of a fluoridated

hydrogen peroxide-based mouthrinse for the treatment of gingivitis: a randomized clinical trial. J Periodontol. 2004 Jan;75(1):57-65.

15. Heinrich-Weltzien R, Weerheijm KL, Kühnisch J, Oehme T, Stösser L: Clinical evaluation

of visual, radiographic, and laser fl uorescence methods for detection of occlusal caries. J Dent Child 69: 127�132.

16. Higham SM, Pretty IA, Edgar WM, Smith PW. (2005) The use of in situ models and QLF

for the study of coronal caries. J Dent. 33(3):235-41. Epub 2004 Dec. 13. 17. Jeon RJ, Han C, Mandelis A, Sanchez V, Abrams SH. (2004) Diagnosis of pit and fissure

caries using frequency-domain infrared photothermal radiometry and modulated laser luminescence. Caries Res. 38(6):497-513.

18. Karjalainen S, Soderling E, Pienihakkinen K. (2002) J Oral Sci. 44(3-4):135-9. An improved

method for detecting mutans streptococci using a commercial kit. 19. Karjalainen S, Soderling E, Pienihakkinen K. (2004) Acta Odontol Scand. 2004

Jun;62(3):153-7. Validation and inter-examiner agreement of mutans streptococci levels in plaque and saliva of 10-year-old children using simple chair-side tests.

20. McComb D, Tam LE. (2001) Diagnosis of occlusal caries: Part I. Conventional methods. J

Can Dent Assoc. 2001 Sep;67(8):454-7. 21. Mendes FM, Siqueira WL, Mazzitelli JF, Pinheiro SL, Bengtson AL. Performance of

DIAGNOdent for detection and quantification of smooth-surface caries in primary teeth. J Dent. 2005 Jan;33(1):79-84. Epub 2004 Dec 08.

22. Nicolaides L, Feng C, Mandelis A, Abrams SH. (2002) Quantitative dental measurements

by use of simultaneous frequency-domain laser infrared photothermal radiometry and luminescence. Appl Opt. 1;41(4):768-77.

23. Nishimura M, Bhuiyan MM, Matsumura S, Shimono T. (1998) Assessment of the caries

activity test (Cariostat) based on the infection levels of mutans streptococci and lactobacilli in 2- to 13-year-old children's dental plaque. ASDC J Dent Child. 65(4):248-51, 229.

24. Oztas N, Bodur H, Olmez A, Berkkan A, Cula S. (2004) The efficacy of a fluoride chewing

gum on salivary fluoride concentration and plaque pH in children. J Dent. 32(6):471-7.


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25. Pienihakkinen K, Soderling E, Ostela I, Leskela I, Tenovuo J. (1995) Comparison of the efficacy of 40% chlorhexidine varnish and 1% chlorhexidine-fluoride gel in decreasing the level of salivary mutans streptococci. Caries Res. 1995;29(1):62-7.

26. Pizzo G, Guiglia R, La Cara M, Giuliana G, D'Angelo M. (2004) The effects of an amine

fluoride/stannous fluoride and an antimicrobial host protein mouthrinse on supragingival plaque regrowth. J Periodontol. 75(6):852-7.

27. Reis A, Zach VL, de Lima AC, de Lima Navarro MF, Grande RH. (2004) Occlusal caries

detection: a comparison of DIAGNOdent and two conventional diagnostic methods. J Clin Dent. 2004;15(3):76-82.

28. Roldan S, Herrera D, Santa-Cruz I, O'Connor A, Gonzalez I, Sanz M. (2004) Comparative

effects of different chlorhexidine mouth-rinse formulations on volatile sulphur compounds and salivary bacterial counts. J Clin Periodontol. 2004 Dec;31(12):1128-34.

29. Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. (1997)

Assessment of dental caries with Digital Imaging Fiber-Optic TransIllumination (DIFOTI): in vitro study. Caries Res. 31(2):103-10.

30. Sengun A, Sari Z, Ramoglu SI, Malkoc S, Duran I. (2004) Evaluation of the dental plaque

pH recovery effect of a xylitol lozenge on patients with fixed orthodontic appliances. Angle Orthod. 74(2):240-4.

31. Silwood CJ, Grootveld MC, Lynch E.(2001) A multifactorial investigation of the ability of

oral health care products (OHCPs) to alleviate oral malodour. J Clin Periodontol. 28(7):634-41.

32. Sreenivasan PK, Gittins E. (2004) The effects of a chlorhexidine mouthrinse on culturable

microorganisms of the tongue and saliva. Microbiol Res. 159(4):365-70. 33. Twetman S, Stecksen-Blicks C. (2003) Effect of xylitol-containing chewing gums on lactic

acid production in dental plaque from caries active pre-school children. Oral Health Prev Dent. 1(3):195-9.

34. Van Loveren C. (2004) Sugar alcohols: what is the evidence for caries-preventive and

caries-therapeutic effects? Caries Res. 38(3):286-93. 35. White GE, Armaleh MT. (2004) Tongue scraping as a means of reducing oral mutans

streptococci. J Clin Pediatr Dent. 28(2):163-6. 36. Wyatt CC, MacEntee MI. (2004) Caries management for institutionalized elders using

fluoride and chlorhexidine mouthrinses. Community Dent Oral Epidemiol. 32(5):322-8. 37. Zhang JZ, Harper DS, Vogel GL, Schumacher G. (2004) Effect of an essential oil

mouthrinse, with and without fluoride, on plaque metabolic acid production and pH after a sucrose challenge. Caries Res. 38(6):537-41.


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ADDENDUM #1 TO THE AAPD COUNCIL ON SCIENTIFIC AFFAIRS Charge #11 This addendum was prepared by Man Wai Ng

Introduction The purpose of this report is to provide a literature review of emerging trends in orthodontics which may be pertinent to the practice of pediatric dentistry. PubMed was used for literature search of miniscrews, distraction and self-ligating brackets. Scientific reports pertinent to this review are listed under �References�. Miniscrews Recently, mini-implants, which are small screws, have been used to enhance anchorage in orthodontics. The advantages of mini-implants include ease of insertion and removal of the screws, immediate/early loading, low cost and adequate anchorage support for orthodontic tooth movement. There have been clinical reports of the viability of using miniscrews for skeletal anchorage to support different orthodontic movements (Kanomi R, 1997, Costa A, 1998 and Schnelle MA, 2004). Distraction Osteotomy Distraction osteotomy (DO) is a procedure that stimulates new bone formation between the surfaces of two divided bone segment under the influence of traction forces. The gap between the bone segments is filled initially with collagen fibers that serve as the mesh in which a callus begins to emerge. Bone formation is initiated by the application of distraction to the soft callus tissue. The generated tension stimulates new bone formation parallel to the vector of distraction (http://www.uihealthcare.com/news/currents/vol3issue2/01distractions.html). DO is used to treat patients with craniofacial abnormalities, including cleft palate, syndromes, different forms of malocclusion, mandibular discontinuity, and obstructed upper airways (Yen SLK, 2005). A significant advantage of DO is the gradual lengthening of the soft tissues and surrounding functional spaces. DO can also be applied at an earlier age than traditional orthognathic surgery (Grayson BH, 1999). Self-ligating brackets Self-ligating brackets have a built-in metal labial face, which can be opened and closed. These brackets have existed since 1935 but they have only recently become popular for use among orthodontists (Harradine NWT, 2003). Design improvements have increased their robustness and ease of use. Presently, there are several commercially available brands of available self-ligating brackets. The advantages of self-ligating bracket systems include low friction, low levels of force needed, and greater control of tooth movements (Garino F,2004). Additionally, self-ligating systems may increase the intervals between appointments and possibly reduce the overall treatment time (Damon DH, 1998).


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References Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary report. Int J Adult Orthodon Orthognath Surg. 1998;13:201-209. Damon DH. The rationale, evolution and clinical application of the self-ligating bracket. Clin Orthod Res. 1998; 1(1):52-61. Garino F, Favero L. Control of tooth movements with the Speed system. Prog Orthod. 2003; 4:23-30. Grayson BH, Santiago PE. Treatment planning and biomechanics of distraction osteogenesis from an orthodontic perspective. Semin Orthod. 1999: 5(1):9-24) Harradine NWT. Self-ligating brackets: where are we now? Journal of Orthodontics. 2003;30:262-273. Kanomi R. Mini-implant for orthodontic anchorage. J. Clin Orthod. 1997;31:673-767. Schnelle MA, Beck FM, Jaynes RM, Huja SS. A radiographic evaluation of the availability of bone for placement of miniscrews. Angle Orthodontist. 2004: 74(6): 831-837. Yen SLK, Yamashita DD, Cross J, Meara JG, Yamazaki K, Kim TH, Reinisch J. Combining orthodontic tooth movement with distraction osteogenesis to close cleft spaces and improve maxillary arch form in cleft lip and palate patients. AJODO. 2005;127(2)224-232. Http://www.uihealthcare.com/news/currents/vol3issue2/01distractions.html.


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ADDENDUM #2 TO THE AAPD COUNCIL ON SCIENTIFIC AFFAIRS Charge #11 This addendum was prepared by Man Wai Ng

Introduction The purpose of this report is to provide a literature review of emerging trends in endodontics which may be pertinent to the practice of pediatric dentistry. PubMed was used for literature search of MTA, and titanium rotary instruments. Scientific reports pertinent to this review are listed under �References�. MTA Mineral trioxide aggregate (MTA)�essentially finely milled Portland cement (lime and silica) with bismuth oxide added�has been shown to have excellent biocompatibility with the dentin and periapical tissues. It been used successfully as a root end filling material or in apical closure cases. It also has been used successfully as a repair material for root perforations. ProRoot� MTA (Mineral Trioxide Aggregate) is marketed by Densply. Dentsply promotes its use for:

• apical plug during apexification • repair of root perforations during root canal therapy • treating internal root resorption • root-end filling material • pulp-capping material

One step apexification with MTA is the best current choice for permanent teeth (Kratchman SI, 2004) Additionally, a few recent studies suggest that MTA may be used successfully as pulp dressing for pulpotomized primary teeth (Agamy HA, 2004 and Salako N, 2003) Rotary Instruments Tintanium instruments used in slow speed (350-400 RPMs) electric handpieces are commonplace and important adjuncts in endodontic practice. Their main attributes are their ability to follow a curve reather than altering the path of the cana (Kim S, 2004). These titanium instruments may have a place in endodontics for primary teeth as well (Barr ES, 1999 and Barr ES, 2000).


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References Agamy HA, Bakry NS, Mounir MM, Avery DR. Comparison of mineral trioxide aggregate and formocresol as pulp-capping agents in pulpotomized primary teeth. Pediatric Dent. 2004;26(4):302-9. Barr ES, Kleier DJ, Barr NV. Use of nickel-titanium rotary files for root canal preparation in primary teeth. 1999; 21(7):453-4. Barr ES, Kleier DJ, Barr NV. Use of nickel-titanium rotary files for root canal preparation in primary teeth. 2000; 22(1):77-8. Kim S. Modern endodontic practice: instruments and techniques. Dent Clin North Am. 2004; 48(1):1-9. Kratchman SI. Perforation repair and one-step apexification procedures. Dent Clin North Am. 2004; 48(1):291-307 Salako N, Joseph B, Ritwik P, Salonen J, John P, Junaid TA. Comparison of bioactive glass, Mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy agents in rat molar. Dent Traumatol. 2003; 19(6): 314-20. Kanomi R. Mini-implant for orthodontic anchorage. J. Clin Orthod. 1997;31:673-767. Costa A, Raffaini M, Melsen B. Miniscrews as orthodontic anchorage: a preliminary report. Int J Adult Orthodon Orthognath Surg. 1998;13:201-209. Schnelle MA, Beck FM, Jaynes RM, Huja SS. A radiographic evaluation of the availability of bone for placement of miniscrews. Angle Orthodontist. 2004: 74(6): 831-837.

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