Oral Health

Rhode Island Pediatric Dentistry Mini-Residency Training Program
Expanded Course Descriptions

SESSION 1:  Caries Management in Pediatric Dentistry

Jim Crall, DDS, ScD

Professor & Chair, Pediatric Dentistry and Associated Clinical Specialties, University of California Los Angeles School of Dentistry. Director, HRSA’s Maternal & Child Health Bureau’s National Oral Health Policy Center.

It is well established that children from low-income households are at significant risk for the development of early childhood caries (ECC) -- a potentially severe form of tooth decay which affects very young children and sows the seeds for dental disease and other health problems later in life. Data from recent national surveys suggest that ECC appears to be increasing in prevalence in the US preschool population. Dental care providers in both the private and public sectors have tremendous potential to help children, families and communities deal with childhood caries -- a condition that remains the most common chronic disease of childhood. But doing so requires that programs, parents and health professionals understand the disease, its consequences, and the full range of what needs to be done to create healthy environments, positive health behaviors, and local oral health care systems that can establish the foundation for a lifetime of oral health for millions of US children. This presentation will provide an overview of current knowledge concerning these three critical topics along with practical tips for overcoming challenges that state and local programs face in securing optimal oral health for all children.

Topics addressed in this course include:

• Dental caries distribution and trends in children, with an emphasis on early childhood caries;
• Understanding caries as a common, chronic, complex, transmissible disease;
• Understanding and applying caries risk assessment in practice and community settings;
• Evidence on effective strategies for reducing caries in children: myths vs. science; and
• Challenges and promising approaches for improving children’s oral health, with an emphasis on early childhood.

SESSIONS 2 & 3: 
Bryan Williams, DDS, MSD, MEd

Pediatric Dentist & Orthodontist, Department of Dental Medicine, Children’s Hospital & Medical Center, Seattle, WA. Affiliate Professor, Departments of Pediatric Dentistry and Orthodontics, University of Washington.

Dentists and staff members who care for pediatric patients are challenged by the complexities of management of child behavior in our dynamic world of competing pressures and differing perspectives.  This fast paced session will provide participants with the opportunity to refresh and update knowledge and skills in practical pediatric behavior management.   The goal is to provide perspective, information and tips useful in everyday practice.  Participants will have a chance to laugh and learn as child temperament, family dynamics, and behavior management strategies are discussed. The presentation also will briefly cover common behavioral adjuncts including nitrous oxide, oral sedation and general anesthesia.

Dr. Williams will focus on practical information for the clinical team.  Some of the specific topics covered are:

• The three defining factors for child behavior
• The developmental ages of children and techniques for assessing developmental age
• Key parameters of behavior for developmental age
• Setting the office environment to enhance success
• The reality of preconditioned behaviors in child patients
• Understanding child temperament and it’s impact on behavior in the dental office
• Parenting in our modern age and how this impacts the dental team
• Management of parental roles in order to enhance success
• Practical techniques for successful everyday practice
• Voice Control
• Tell, Show, Do
• Do, Do, Do
• Positive Reinforcement
• Power of Touch
• Distraction
• Imagery
• Modeling
• Contingent Rewards
• Time Out
• What about the Non Compliant Child?
• Judgment parameters and techniques when you just have to get it done
• Nitrous Oxide – Happy Air and how to make it work well
• Oral sedation- judgment parameters and agents that are safe and effective

SESSION 4:  Orofacial Trauma
Isabelle Chase, DDS, FRCD(C)
Clinical Instructor, Pediatric Dentistry, Children’s Hospital Boston. Pediatric Dentistry Pre-Doctoral Program Director, Harvard School of Dental Medicine.
This one-hour introduction to dental traumatology is designed to provide the general dentist, hygienist, and auxiliary dental staff with an update on the epidemiology, diagnosis, and treatment of soft and hard tissue orofacial trauma. The focus will be on emergency treatment of both primary and permanent tooth fractures (uncomplicated and complicated) and displacement injuries (luxations and avulsions). Current treatment guidelines as well as emerging treatment will be discussed. In addition, management of alveolar fractures and soft tissue, as well as sequelae of primary tooth trauma and legal aspects of trauma (including child abuse) will be reviewed.

Objectives

Upon completion of this lecture, participants should be able to:

• Take an accurate trauma history.
• Properly diagnose orofacial injuries in the primary and permanent dentition both clinically and radiographically.
• Treat primary and permanent tooth fractures of enamel and enamel/dentin
• Understand differences in the treatment of pulp exposures in the immature and mature permanent tooth.
• Treat root fractures in the primary and permanent dentition.
• Treat displaced and avulsed teeth.
• Counsel patients and parents on prevention of orofacial trauma.
• Understand the long-term clinical and radiographic findings following trauma to the primary and permanent teeth.
• Recognize signs of child abuse and follow-up appropriately.
• Have a better understanding of the management of alveolar fractures and soft tissue trauma.

SESSION 5:  Growth, Development, & Management of the Developing Dentition

Stanley Alexander, DMD

Chairman & Professor, Department of Pediatric Dentistry, Tufts University School of Dental Medicine. Consultant, Department of Dental & Oral Surgery, Brookdale University Hospital Medical Center.

Craniofacial Bone Growth: Mechanisms & Theories
Bone growth and development includes the development of bony structures from non-calcified precursors, and remodeling changes that occur with changing function and as the individual matures. The two mechanisms of osteogenesis, i.e., intramembranous and endochondral are discussed.  Lecture participants should review previous anatomy notes on the subject.  Once an anatomic bone has formed, it undergoes constant remodeling changes as an individual advances through the fetal, neonatal, infant, child, adolescent, and adult stages. Several theories have been postulated to explain this correlative growth and are reviewed in the lecture.

Objectives
The participant should:

• Be able to list the two mechanisms of osteogenesis.
• Know, in general those areas of the craniofacial complex that evolve via the intramembranous and endochondral mechanisms.
• Know what is meant by the following terms in relation to bone remodeling:
• Drift
• Displacement
• Relocation
• List and discuss methods used for studying bone growth and development.
• Know the controlling factors and theories in craniofacial growth.
• Be familiar with the development of the cranial base, cranium, maxilla, and mandible.

Craniofacial Growth related to Body Growth

In an effort to predict what growth changes in the craniofacial area will occur, investigators have attempted to relate craniofacial growth to other aspects of body growth. These studies have given us long-term case histories of many individual’s growth patterns and numerous “average” dimensional changes calculated for various population groups. However, these studies have also shown that on an individual basis the dimensional changes due to facial growth are exceedingly variable and as of now we have no successful way of predicting the facial growth pattern of a single individual.  Nevertheless, investigators continue to search for somatic growth variables which might be closely related to craniofacial growth and thus allow us to more accurately predict craniofacial growth.  

Objectives
The participant should:

• Be familiar with the known principles of growth.
• Know the “ages” by which humans may be evaluated.
• Know the subdivisions of biological age.
• Know that differential growth rates and patterns of growth exist.
• Know the patterns of growth for various body tissues.
• Understand the general growth patterns of the craniofacial region.
• Know the relationship between maximal growth in height to maximal facial growth in the pubertal period.
• Be aware of different patterns of growth in males and females.
• Know which bones are most frequently used on hand-wrist films to predict craniofacial growth.

Prevention and Interception of Malocclusion: Premature loss of primary teeth, space maintenance, space regaining, habits
One of the functions of the primary teeth is to serve to maintain space for the succedaneous permanent teeth.  The untimely loss of one or more primary teeth may lead to a decrease in arch length and circumference, impede the eruption of succedaneous teeth, and produce a malocclusion in the permanent dentition.  When one or more primary teeth have been lost prematurely, consideration must be given to maintaining the space formerly occupied by the primary teeth in order to prevent loss of arch circumference and length and to allow the permanent successor to erupt unimpeded.  

In this topic, the following will be discussed: appliances for space maintenance, general considerations for space maintenance (presence or absence of a permanent successor, space analysis, time elapsed since loss of the primary tooth, stage of development and emergence of the permanent tooth, state of emergence and occlusion of the 1st permanent molars, eruption and sequence of the permanent teeth).

Objectives
The participant should:

• Be able to discuss, in general, the effects of premature loss of a primary tooth on the developing occlusion.
• Know the relative order of potential space closure following premature loss of each of the primary molars.
• Be familiar with the design, or appearance of some of the common types of fixed and removable space maintainers
• Know what is meant by functional and non-functional space maintainers.
• Be able to discuss the general considerations which are important when deciding whether a space maintainer is indicated.
• Know at what stage of root development permanent canines and premolars usually clinically emerge.
• Know under what circumstances space maintenance is indicated for the primary incisors, canines, and first and second molars.
• Know what appliances are recommended and why.
• Be familiar with and be able to discuss the unfavorable sequelae associated with the use of space maintainers.

Space Regaining
 “Space loss” refers to a decrease in arch length and arch circumference with a reduction in the total amount of space available in the arch for the succedaneous teeth. This may result in a crowded dental arch or a blocking out of individual teeth.

Objectives
The participant:

• Should be able to describe the consequences of early primary tooth loss before, during, and after the eruption of the 1st permanent molars.
• Know how the forces of occlusion and eruption influence tooth positions when early loss of a primary molar has occurred.
• Know the effect of the amount of leeway space, height of the cusps of the permanent molars, and the age of primary molar loss on the amount of mesial drifting of maxillary molars.
• Be familiar with the indications and contraindications for space regaining.
• Be familiar with the use, advantages, and disadvantages of space regaining  appliances.
• Be aware of the need to retain teeth in position after space regaining.

Habits
A habit is a learned pattern of muscle contraction. Certain oral habits can be detrimental to the proper development of the occlusion and jaws. Thumb sucking and tongue thrusting are normal activities at a particular stage of development which, if retained, can become abnormal activities which can either cause a malocclusion or aggravate an already existing malocclusion. This section will be concerned with these habits as normal activities and as abnormal activities, and their potential detrimental effects upon oral structures.

Objectives
Participants:

• Should know what is meant by nutritive and non-nutritive sucking.
• Should know beyond what age thumb sucking is considered to be detrimental to the development of the jaws and occlusion.
• Should list and describe the effects of thumb sucking and tongue thrusting and associated abnormal muscular patterns on the anterior teeth, alveolar bone, posterior teeth, and basal bone.
• Should know what is meant by an infantile swallow and somatic swallow.
• Should know what appliances are available to treat detrimental habits.

SESSION 6:  Oral Medicine & Oral Pathology

Ellen Eisenberg, DMD
Professor, Department of Oral Health & Diagnostic Sciences, Division Chair, Oral &Maxillofacial Pathology, University of Connecticut School of Dental Medicine. Associate Professor, Department of Pathology, University of Connecticut School of Medicine.

In this session, we will discuss the more commonly occurring non-infectious and infectious oral mucosal conditions affecting pediatric dental patients that are often associated with or characterized by ulceration and pain.  Because their clinical features tend to overlap, many of these diverse conditions are diagnostically confusing and can pose management challenges to even the most astute clinician.  Therefore, it is important for the pediatric dentist to know their classic clinical presentations and their typical histories.  The clinician should have contemporary understanding of these respective conditions’ underlying etiology and pathogenesis, so that reasonable differential diagnoses and accurate diagnoses can be established expeditiously.

A few select examples of oral ulcerative conditions both of local and systemic origin will be presented to illustrate current approaches to diagnosis and disease management.  We will discuss traumatic ulcers, recurrent aphthous stomatitis and systemic conditions characterized by aphthous-like lesions, selected viral infections, and some relevant hereditary conditions that occasionally must be considered in differential diagnoses.  The discussion will focus on the importance of good observations, accurate description and history as keys to the diagnostic process, and for understanding the rationale underlying effective approaches to treatment.  This will also enable the provider to institute appropriate management and patient-parent/guardian counseling.  Time permitting, a brief discussion of mucositis and its management in the child patient undergoing antineoplastic therapy will also be addressed.

SESSION 7 & 8: Restorative Techniques & Treatment Planning for the Pediatric Dental Patient

Michael Kanellis, DDS, MS

Dean for Patient Care, Professor of Pediatric Dentistry and Director, Advanced Training Program in Pediatric Dentistry, The University of Iowa College of Dentistry.

These sessions will focus on restorative techniques and treatment planning for the pediatric dental patient.  Of particular interest will be the treatment planning and restorative care of young children with early childhood caries.  The list of topics to be covered, along with a brief explanation follows.

Stainless Steel Crowns
Tried and true, stainless steel crowns are loved by pediatric dentists, but general dentists often do not feel comfortable placing them.  A review of the literature will demonstrate the superiority of stainless steel crowns to multi-surface restorations in young children. Indications for placement of stainless steel crowns will be reviewed, and two techniques for tooth preparation and stainless steel crown placement will be reviewed.

Anterior Restorative Materials and Anterior Esthetic Crowns
The restoration of decayed or missing primary incisors is especially challenging.  A technique for placing composite strip crowns will be shared. In addition, prefabricated esthetic anterior crowns will be reviewed, and a technique for replacing missing primary anterior teeth will be shown.

Atraumatic Restorative Treatment (A.R.T.)
The atraumatic restorative treatment technique (A.R.T.) was developed by the World Health Organization for use in third world countries where dentistry and electricity are often not available.  The technique has been successfully modified in the United States for use with pre-cooperative children with early childhood caries.  The modified technique (coined “Alternative Restorative Technique” by the American Academy of Pediatric Dentistry) will be reviewed along with a rationale for selecting the ideal restorative material for this technique.

Resin Modified Glass Ionomer – Uses in Restorative Pediatric Dentistry
Glass ionomer products have been widely used in pediatric dentistry. Some of their inherent limitations can be overcome by using a resin-modified glass ionomer (RMGI).  The rationale for considering the use of RMGI’s in pediatric dentistry will be shared, along with recommendations for treatment situations where they should be employed.

Pulp Therapy – Update on Pulpotomy & Pulpectomy Techniques
Formocresol pulpotomies have long been considered the “gold standard” for pulp therapy in vital primary teeth.  However, increasing awareness and concern over the clinical use of formaldehyde has strengthened our resolve to find an alternative treatment.  Possible options will be discussed, including a recently emerged pulpotomy technique utilizing sodium hypochlorite.  For treatment of non-vital primary teeth, a pulpectomy technique using Vitapex will be shared.  Finally, the subject of indirect pulp capping in primary teeth will be reviewed and recommendations made.

Review of Gingival Diseases in Children
A brief review of gingival diseases in children will be presented.

Considering the Extraction of Severely Decayed First Permanent Molars
A treatment dilemma that faces most dentists at some time is whether to restore or extract severely decayed first permanent molars in young children.  This section of the presentation will review factors that need to be considered prior to making a recommendation.  Cases will be reviewed where first permanent molars have been extracted.

Review of Radiographic Guidelines
Take the guesswork out of prescribing radiographs.  Established radiographic guidelines provide a consensus opinion on which radiographs should be taken and when.  Familiarity with published radiographic guidelines will help doctors and their staff decide on the appropriate radiographs for their patients.

At the end of this presentation, participants will have a better understanding about available restorative treatments for pediatric dental patients, and about treatment planning in difficult circumstances.  Participants should be able to immediately apply several treatment and treatment planning strategies to their daily practice.

SESSION 9:  Hospital Dentistry

Daniel Kane, DMD

Dental Director, St. Joseph Hospital for Specialty Care and Associate Director, Advanced Education in Pediatric Dentistry, Lutheran Medical Center/St. Joseph Hospital for Specialty Care.

Joseph Samartano, Jr., DDS
Chief, Division of Dentistry and Oral & Maxillofacial Surgery, Attending Dentist, Pediatric Dentistry Residency Program, St. Joseph Health Services of Rhode Island.

Hospital dentistry focuses on serving those patients who cannot receive dental care through the traditional delivery systems.  Patients who are medically and/or mentally compromised, or whose age or behavior present a challenge to dental treatment in a clinic or private practice setting maybe successfully treated in a hospital practice.  Hospital dentistry renders the full range of surgical, restorative, consultative, maintenance and preventive outpatient procedures offered through other practice settings.  The hospital practice also offers services for restorative and surgical procedures completed under general anesthesia.  This session will present the considerations associated with patient selection and successful treatment outcomes in the hospital setting.  The session will feature a case study and video of an actual operating room case competed at Fatima Hospital.

SESSION 10:  American Academy of Pediatric Dentistry Oral Health Policies & Clinical Guidelines

PANEL:  RI Pediatric Dentists

Rhode Island Pediatric Dentists agreeing to participate on the panel, as of April 26, 2007:  Fotini Dionisopoulos, DMD; George Dupont, DDS; Craig Elice, DDS; Daniel Kane, DMD; Thomas Mulvey, DDS; Brian Shannon, DDS; George Vezina, DDS

The American Academy of Pediatric Dentistry (AAPD) is the membership organization representing the specialty of pediatric dentistry.  The AAPD, in accordance with its vision and mission, advocates improved oral health for all children.  The AAPD Reference Manual (Oral Health Policies & Clinical Guidelines) is one of the components of the organization’s advocacy activities. 

The AAPD Reference Manual is intended to encourage a diverse audience to provide the highest possible level of care to children and is divided into five sections: (1) definitions; (2) oral health policies; (3) clinical guidelines; (4) endorsements; and (5) resources.  The AAPD Reference Manual contains practice guidelines which are intended to be recommendations for care that could be modified to fit individual patient needs based on the patient, the practitioner, the health care setting, and other factors.  All participants in the Mini-residency will receive a copy of the reference manual.

A panel of Rhode Island pediatric dentists will discuss the American Academy of Pediatric Dentistry (AAPD) Oral Health Policies & Clinical Guidelines and respond to audience questions generated during the course of the program.  This session also will provide an opportunity for participants to meet Rhode Island’s pediatric dentists and share expertise.