A Very Happy Christmas and a Prosperous New Year
To All Members of EAPD from Leeds Paediatric Department
I would like to wish you all a Merry Peaceful Christmas and a happy New Year with good health and prosperity! In addition I wish you continued success in your professional life in paediatric dentistry.
Since the start of the new academic year time has passed rapidly. Since the previous newsletter all councillors have received the first presidential letter encouraging them to participate more in the newsletter. In the present issue you will read some information on Paediatric conferences in Sweden, Germany and the UK. There is also an article on Paediatric Dentistry in Norway by M. Raadal. I’m very pleased that the editorial board succeeded in editing a 5th newsletter in 1998. and fulfilled their promise. For 1999 we will revert to four issues. In addition the first draft of a full journal article on `Guidelines on the use of fluoride in children' is prepared by C. Oulis and I expect submission to the international literature before the next newsletter.
Concerning the recognition of the speciality there is again negotiation at European level and C. Oulis is following that closely. There is some light in the dark and he will report on that in the next issue. It was very important that the speciality was recognised in the UK in July 1998. In Belgium a task force was nominated to prepare a document in order to propose which specialities should be recognised and what criteria should be defined to recognise specialists and Paediatric Dentistry will be included in that important document.
In the previous letter I announced the formation of new working groups in order to produce faster EAPD policy documents. Councillors were invited to select a proposed tropic or to propose another topic or nominate other specialists to participate. I' m still waiting for some answers but I feel we will start with `pit and fissure sealant' and X-rays in children. Other items such as antibiotic use, trauma and disruptive behaviour are pending. I will announce the new working groups in the next letter.
Finally, an executive meeting will take place in Brussels on Friday March 19th 1999 preceding an international symposium on restorative paediatric dentistry March 20th organised by the Belgian academy.
Luc C Martens
Jack and I had waved our respective children goodbye, visions of their anxious faces in our minds as they embarked on the first day of a new school year. However, the academic challenges of the BSPD Conference lay ahead of us. Jack in Indiana Jones mode combated the obstacles on the M62 ducking and diving, foot hard down until we reached `the other side' of the Pennines ... and came to a grinding halt. Having survived the troops of frustrated commuters we arrived in Manchester to be greeted by ... you guessed it ... torrential rain! (It was sunny when we left Yorkshire!)
We arrived at the Teacher's Conference late and wet like two naughty school children and were subsequently put at the front of the proceedings! All the hassles of our journey were quickly smoothed away by the warm and friendly welcome of Ian Mackie and his team.
The Teacher's Conference was preparing for Subject Review and TQA. Excellent presentations were delivered in an interactive style, emphasizing the role of the tutor, counselling skills, access to counselling services and the need for a structure to enable students to access these Services. The afternoon session enabled us to listen to a report on Glasgow's and Dundee's performance in the TQA experience.
The conference facilities at UMIST were excellent and the catering was superb. It was wonderful to have all the facilities on one site. I spent a `quiet evening in' whilst others sampled the ultimate night life experience in Manchester (the Gay Village was mentioned)!
The BSPD Research prize presentations took place on Thursday with excellent contributions by young researchers followed by the trade exhibition and poster presentations. I found the Poster by Roberts, et al. On bacteraemia following placement of restorations particularly interesting. Trainees presented case reports in the afternoon displaying excellence in clinical care.
A sparkling wine reception was a much-needed reward at the end of a busy day, followed by a wonderful meal rekindling old and forming new friendships. The pub style quiz was a ‘hoot’, I have to confess that I was a member of ‘Mr. Viagra’s Hareem’ - a laugh a minute but low on the Krypton factor!
Friday was the `piece de resistance' of the Conference with presentations on Dental Trauma by Frances Andreasen. I found that I did not learn anything new from this experience as the management of Dental Trauma has been taught to an excellent standard on the MSDc at Leeds Dental Institute and I found that Frances was not open to discussion of other treatment philosophies, i.e. the Australian penchant for ledermix and hypocal. However, I will be the first to look out for the Muksgaards publication of the essentials of the essentials!
The Manchester team had organized a superb ‘40’s' theme night at Dunnammassey Bowden. The Les Peters Dance Band blew their hearts out. my old friend Patricia Sweeney Henzall (an ex Teacher in Ballroom Dancing) and dancer extraordinaire had her little book filled with names all night long ... Ah well destined to be a wall flower.
Still waving our flags and gathering up action men on parachutes (souvenirs for the kids of course) we retired late. The remedy for the morning after the night before feeling was the excellent well-structured presentations challenging our thoughts on the use of dental materials for the millennium. The Conference was exceptionally well organized and our congratulations must be offered to Professor Blinkhorn and Ian Mackie and their team.
The perilous journey across the M62 was slightly delayed by a fire alarm - we vacated UMIST to find snow and hail on the ground! Ah well, somethings will never change!
SYMPOSIUM ON REFINED RESTORATIVE PAEDIATRIC DENTISTRY
BRUSSELS Saturday 20th March 1999
· Prof Dr Raadal: Interceptive versus restorative caries therapy in preschool children
· Dr Oulis: Strategies for diagnosis and management for early carious lesions in the mixed dentition
· Prof Dr Curzon: Stainless steel crowns: a preventive restoration?
· Prof Dr Verbeeck: Compomers: Classification and mechanisms
· Dr Marks: Clinical results of poly acid modified glass ionomers
· Prof Dr Martens: Restoring primary teeth in a preventive perspective
The next EAPD Congress is to be held in Bergen, Norway, in June 2000. The members might be interested in knowing some facts about Paediatric Dentistry in our country, particularly for those of you who are planning to come to Norway and participate in the Congress. In this and coming issues of the Newsletter I will try to highlight details that might be of interest.
Ø According to the Norwegian Dental Association (more than 95% of the Norwegian dentists are members) their practising members were distributed as follows in 1998:
2419 private practitioners
1280 in the Public Dental Health Service
183 in Universities
65 in other public organisations
177 student members
About 30% were females.
Ø The great majority of children (more than 90%) are treated in the Public Dental Service (PDS) which offers free treatment for all children from birth through to their l8th year of life. PDS defines this group of children as their priority group number one, while handicapped patients of all age groups constitute priority group two. The children are regularly called to the local public clinic, usually from age 3, and they are followed by regular check ups (1-2 years intervals) until the year they become 19. Children of age group 0-3 years are only seen in the clinics on request from other health personnel or parents, usually because of obvious oral health problems or trauma. All kinds of treatment, except orthodontics, are free of charge for the children.
Ø According to the body of rules for the PDS ( 1983), preventive treatment should have higher priority than restorative. The main reason for this move was the decreasing caries rate during the 70’s, extremely welcomed after having increased through the 50’s and 60's, and the belief that this success was the result of preventive implementations made by the PDS. There was a strong belief in all kinds of fluoride applications, tablets, rinsing, brushing and topical applications. This has later been questioned by many researchers who attribute the majority of the decreased caries prevalence to increased usage of fluoride dentifrice and improved oral hygiene in the population.
Ø Norwegian official statistics on the caries prevalence among children are based on annual reports from all public clinics on 5-, 12- and 18-year-old children. These are some key data from 1996:
70% of the 5-year-olds had dmfl=0
Mean DMFT was 1.8 among 12-year-olds, and 43% were caries free
Mean DMFT was 6.2 among 18-year-olds, and 12% were caries free
It is a fact that these data are based on the dentists' decision on making restorations and is therefore a considerable underreporting of clinically visible dental caries. And, since the criteria for making restorations in children’s teeth have changed during the last 10-20 years in the direction of being more restrictive with use of restorative treatment for incipient and small lesions, it seems obvious that much of the reported caries decrease is caused by this change in treatment strategy.
Ø Norway has only 25 recognised Paediatric Specialists, and many of these are employed by the two dental faculties. The great majority of dentists treating children in the PDS are therefore General Practitioners. This does not mean that PDS delivers dental treatment of poor quality to Norwegian children. Children's dentistry has long and strong traditions in our country, and this is well taken care of in the undergraduate curriculum for dental students. Norway took a piece of European dental history when Guttorm Toverud became the first Professor in Paediatric Dentistry in 1932, and this certainly gave our field a powerful position within the country as well as abroad. And, since PDS has made children their first group of priority, much of its interest and concern for increased quality is concentrated on this group. As a result of this, the population is well satisfied with the PDS for their children, and the Public Dentists are recognised as well qualified Paediatric Dentists in Norway. It seems reasonable to estimate this group of dentists as potential associate members of the EAPD.
Ø Why are we so few Paediatric Dental Specialists in Norway? The main answer is given above. The Norwegian PDS has not seen the great need of Specialists since their General Practitioners are so well skilled. They have therefore not encouraged their dentists to take postgraduate education in this field, and very few positions for Specialists have been established (in contrast to Sweden). And the market for Private Practising Paediatric Dentists is poor since the PDS takes care of almost all children. As a consequence of this, the number of applications to the postgraduate program at our two dental faculties has been very small. This is certainly not an optimal situation for Children's Dentistry, because there are many special cases that need more advanced examination and treatment than most General Practitioners are able to deliver.
Ø The interest among the 25 Paediatric Dental Specialists in Norway to become members of the EAPD has been very moderate up to now. One of our major goals when we applied for the 5th EAPD Congress to be held in Norway, was to put emphasis on Specialised Paediatric Dentistry in our country, and to stimulate Norwegian Dentists to become members of the EAPD. We believe both these issues will contribute to an increased focus on Specialised Paediatric Dentistry in Norway.
More from Norway and Bergen in next issue of the Newsletter.
The annual meeting of the Gesellschaft fur Kinderzahnheilkunde in der DGZMK took place on the 25th and 26th of September 1998 in Dresden, Germany. The Congress was highlighted by a large number of scientific presentations concerning new diagnostic methods in Paediatric Dentistry. The second main subject covered the monitoring and care of the developing dentition.
Prof. Dr. B. Angmar-Mansson (Karolinska Institute. Sweden) reported on advances in caries diagnostic including QLF (Quantitative Light-induced Fluorescence) especially concerning the diagnosis and monitoring of smooth surface lesions and fissure caries. Electric current measurement (ECM) was also discussed for the diagnosis and monitoring of fissure caries. These methods enable the practitioner to quantify the progression of cavity formation. They help determine when and how to intervene, how caries-prone the patient is at the time of testing and can encourage and motivate the patient to further endeavours in oral health.
Prof. Dr. Dr. L. Stober (Dept of Preventive Dentistry, Jena, Germany) lectured on the predictors of caries development and active oral disease. He discussed the quantification of basic aetiological and predisposing factors. The patient population with a high decay experience should be predicted as early and as precisely as possible with clinical and laboratory parameters exhibiting a high sensitivity and specificity. He especially stressed the importance of the initial caries lesion (IS) as a dependable parameter which can be monitored for progression by methods discussed in the previous lecture. This allows for a more effective treatment plan and earlier interceptive therapy. Saliva testing in order to monitor and maintain oral health was recommended only for healthy patients who have stopped the decay process by complete dental care.
The progression, stagnation and remission of initial caries lesions was demonstrated in the scientific report by PD Dr. R. Heinrich-Weltzien et al (Erfurt). Initial caries lesions on smooth surfaces and in fissures of the teeth of 6 to 7 year old children were analysed dynamically over a period of 4 years.
Mutans streptococci tests were used in an attempt to determine the emergence of fissure caries prospectively in the scientific report by Dr. Christian Splieth et al (Greifswald). It was found that the sum of all diagnostic parameters was more important than the Mutans streptococci counts alone.
PD Dr. B. Irmisch et al (Dresden) presented a study on the prediction of oral disease in very young children. They reported on the difficulties involved in predicting the decay process by saliva-testing, hygiene and diet parameters.
PD Dr. Andreas Schulte et al (Heidelberg, Marburg ) were able to answer some questions about ECM results in their scientific report on post-eruptive changes in electrical resistance of premolars. Their results show that teeth in the eruptive stage (up to the 15th post-eruptive month) have low ECM rates, thus affecting the specificity of this method for the diagnosis of occlusal caries.
Dr. C. Hirsch et al (Halle-Wittenberg) compared two screening methods for the identification of children with a high caries risk. There were a number of posters concerning the identification of children prone to decay, most of them dealing with saliva-testing but also including laser diagnostic and screening methods.
Dental materials were discussed in a separate session including the fluoride release of two composites compared to compomers and glass-ionomers (Prof Dr. U. Schiffner et al Hamburg). Composite adhesion to carious dentine in deciduous teeth was discussed (Dr. R. Frankenberger et al Erlangen). The flow properties of the new "Flow" composites were reported on by Dr. M. Schoch et al (Erlangen).
Dr. H. Schuster et al (Halle-Wittenberg) concluded in their scientific report on the quality and retention of composite sealants containing fluoride, that the filler has no effect on the retention of the sealant but unfilled sealants have a higher incidence of air bubbles and marginal defects. They recommend using filled fluoride releasing sealants.
Fewer amalgam fillings are being placed in the teeth of young school children. First grade pupils had 80% of their fillings made of tooth-coloured restorations whereas only 50% of the fourth graders and 33% of sixth graders had restorations in tooth-coloured materials (Dr. G. Pfaff et al Stuttgart, Aalen, Marburg).
Epidemiological reports discussed the oral status of children being treated for oncological diseases (D. K. Wende et al, Mainz) and 720 school children in a German city (Prof. Dr. B. Willershausen-Zonnchen et al, Mainz). The effect of a dental consultation on the dental behaviour of families with small children was positively reported on by Dr. G. Grabler et al (Dresden). Less effect was found by the same consultation on the behaviour of families with pre-school children having a high risk for decay (Dipl. -Stom. R. Zimmerman, Dresden).
Dr. L. Lindner et al (Marburg; Osnabruck) reported on their research on the differences in oral health between German-born children and Russian immigrants. They found the largest difference in the two groups among the 3 to 6 year olds whereas the 12 year olds presented almost no differences in caries experience.
Dr. B. Zschieschack (Rostock) reported on the increase in oral disease among physically handicapped children after discontinuing collective fluoride treatments in a school for the handicapped in Rostock, Germany.
The monitoring of the developing dentition was presented in two main lectures. The optimal timing for orthodontic preventive care and treatment was investigated in a presentation of normal and abnormal development of the dentitions of 8700 Dresden school children. (Prof Dr. Winfried Harzer, TU Dresden)
Interceptive orthodontics was reviewed by Prof Dr. Dieter Mubig (Regensburg).
Short lectures were presented dealing with epidemiological factors in orthodontics and paediatric dentistry (Prof Dr. R. Grabowski et al, Rostock), ankylosis of primary teeth (Dr. G. Viergutz et al, Dresden), compliance problems in the monitoring of the dentition (Dr. W. Kamann et al, Witten) and the spontaneous movement of the permanent tooth germs (Dr. I. Storr et al, Munchen).
Free presentations covered a wide range of subjects including the aesthetics of orthodontics, pathological processes at the apices of both primary and permanent dentitions, the efficacy of electrical toothbrushes, the use of saliva cortisol measurements as a parameter of stress in the child patient, to name but just a few.
In the general assembly concluding the meeting the members of the society elected a new board for the coming year.
Prof. Dr. G. Hetzer (Dresden) was re-elected as chairwoman of the board; Dr. C. L. Butz (Munchen) was elected vice-chairwoman and Priv.-Doz. Dr. N. Kramer was re-elected as secretary of the board.
For the past 5 years the Swedish Academy of Paediatric Dentistry has arranged a one and half day course for the Paediatric Dentistry team. i.e. dentists, dental nurses and dental hygienists.
It has been quite a successful event and usually attracts about 300 delegates every year. The location of the annual meeting has varied each year in order to make it possible for as many people from the various parts of Sweden to attend. As you may be aware Sweden has some fairly large distances between its cities, even if we are a small country! The distance from the north to the south of Sweden is about 2500 km!
The topics of this year's meeting were:
1) Ethical considerations, where Dr. A-L Hallonsten and a child psychiatrist, Dr. U Ryda, discussed among other things questions about the children’s right to dental care and to a society with resources for oral health and their right to informed consent, secrecy, integrity and autonomy. The lecture provoked many questions both put forward by the audience, but also to be taken home for more personal thinking and considerations.
2) Radiographic diagnostic techniques regarding caries where Professor H-G Grondahl described and discussed digital systems and their diagnostic values. There is a great dimension of development in this area, but ordinary radiographic techniques are still very useful. It is important with individual indications, not to use underexposed pictures and to have control over the development procedures.
3) Restorative treatment of the primary dentition. The following lectures started with the use of Carisolv and thereafter to the more conventional restorative treatment of the primary dentition with due consideration to the choice of filling material. Drs J Van Dijken and I Wenckert-Andersson gave a thorough presentation of current dental materials, glass ionomer cements, resin reinforced glass ionomer cements, "compomers" and composite resin materials. Their choice of dental material for various clinical situations were based on good clinical studies. Many of us felt much less confused and returned to our clinics with more confidence and knowledge in our future choice of dental materials.
4) Community oral health. The course ended with a lecture by Dr J Paulander on oral health on a community level. With the aid of computerized systems, epidemiology could be studied on both individual (patient) and group levels, in relation to various health variables, risk factors and risk assessment. Furthermore, analysis of dental care systems instituted could be studied regarding oral health in relation to measures taken, treatment performed and time consumption.
These very interesting lectures were accompanied by a dental trade exhibition and of course there was a very enjoyable social programme.
Effects of Intracanal Medicaments on Inflammatory Resorption or Occurrence of Ankylosis in Mature Traumatised Teeth.
Endodontics and Dental Traumatology 1993;9:175-184.
The use of calcium hydroxide as an intracanal medicament is widely accepted, generally without concern, for the prevention of external root resorption in traumatised permanent incisors. This paper questions its use and challenges the interpretation of the literature and also proposes alternative medicaments, which do not find wide acceptance but have shown to be effective in combating external resorption. The authors review over 30 relevant papers and first set the scene by presenting a critique of the effects of calcium hydroxide on both inflammatory and replacement resorption and the development of ankylosis. It is apparent that there is sufficient evidence that calcium hydoxide is effective in preventing inflammatory resorption in mature teeth, possibly by targeting the resorbing cells of the PDL. However, they argue that if the endodontic treatment is initiated early enough and the root canal obturated well with gutta-percha and a sealer, resorption would also not occur. A major disadvantage of calcium hydroxide, in those cases where there has been a severe injury to the PDL, is that it might seep out into the PDL space and by the virtue of its irritant properties derived from its alkalinity, might cause further inflammation of the PDL cells and promote ankylosis. Therefore, in cases of avulsion and intrusion, the early use of calcium hydroxide might be counter productive. On the other hand the use of medicaments such as Ledermix has been shown to reduce inflammation of the periodontal cells in vitro. Animal studies have also indicated that ledermix might have a direct inhibitory effect on the resorbing cells without causing damage to the cells of the PDL as could be the case with calcium hydroxide.
Based on these observations the author makes several sensible recommendations on the use of intracanal medicaments. The most logical recommendation is that in cases of traumatic injuries where there has been severe damage to the PDL, as is the case in intrusion and avulsion, the use of calcium hydroxide after pulp extirpation should be delayed until the healing of the PDL cells has taken place. The canal could be filled with a paste, such as ledermix, which does not damage the healing PDL cells.
The paper is extremely well written and the authors are merciless in their review of the literature and its traditional interpretation. However, some of the conclusions and recommendations are based on very scanty evidence. The use of ledermix might sound sensible due to its non-irritant properties, but there is insufficient evidence for its widespread use as a root canal dressing material for traumatised young permanent teeth. Calcium hydroxide should be the medicament of choice but the dressing of the root canal with it should perhaps be delayed till PDL repair has occurred.
Replantation of 400 Avulsed Permanent Incisors.
1. Diagnosis of Healing Complication.
Andreasen, JO, et al.
Endodontics and Dental Traumatology 1995;11:51-58.
Replantation of avulsed permanent incisors is an accepted treatment but one where the prognosis remains questionable. The reasons for the unpredictable prognosis are a variety of factors that have an influence on the outcome of treatment. This paper, first in a series of five, studied the long-term survival rate of replanted incisors and the extent of pulpal and periodontal complications.
A large number (400) replanted permanent teeth were followed up retrospectively. The teeth had been replanted between the years 1965-1988. Using methods well documented in the literature the authors studied the pulp and periodontal healing, gingival healing and the loss of marginal attachment, root development and the overall percentage of tooth loss. In addition, the relationship of all these parameters with the stage of root development at the time of replantation was also studied.
The results of the study showed that overall some thirty percent of replanted teeth had been extracted. Interestingly, more teeth with incomplete root development were lost as compared to teeth with complete root development. The pulp healing was poor for the whole group but was significantly higher for teeth with incomplete root development (34%) as compared with only 8% overall. The periodontal healing was studied radiographically as a measure of external root resorption. Only 24% of the teeth had demonstrated PDL healing without any signs of resorption, with teeth that had a complete root development showing significantly poorer PDL healing.
This study is of tremendous importance because it studied a large number of factors in a very large sample. Established criteria were used for as, assessing various parameters. It is one of a few studies that have provided evidence that teeth with incomplete root development have over a thirty percent chance of revascularisation, but if this does not happen their long-term prognosis is poorer that those with a complete root development. This aspect is of importance in treatment planning with the advent of alternative treatments such as transplantation. The implication of poorer prognosis of teeth with open apices, which become non-vital after replantation is that transplantation can be planned at an early stage. The authors acknowledge that the splinting strategy had evolved over the last three decades and later in the series do correlate the period and method of splinting with the PDL healing.