Dental RECUR Randomized Trial to Prevent Caries Recurrence in Children

The purpose of this study was to determine the efficacy of a dental nurse-delivered intervention-the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI)-in reducing the recurrence of dental caries in children who have a primary tooth extracted. It was based on a 2-arm multicenter randomized controlled trial with blinded outcome assessment. Participants were 5- to 7-y-old children (n = 241) scheduled to have primary teeth extracted in 12 UK centers. Test intervention parents (n = 119) received DR-BNI led by trained dental nurses. DR-BNI is a 30-min structured conversation informed by motivational interviewing with a forward focus to prevent future caries. Preventive goals are agreed, and a review appointment is made with child's general dental practitioner, who is advised to treat the child as being at high caries risk. The control intervention (n = 122) was a parent-nurse conversation about child's future tooth eruption, with advice given to visit a general dental practitioner as usual. At baseline, the DR-BNI group's mean dmft was 6.8, and the control group's was 6.3. A median of 5 teeth were extracted, mainly under general anesthesia. Final dental assessments were conducted by a single examiner visiting 189 schools 2 y after intervention; 193 (80%) of 241 children were examined. In the control group, 62% developed new caries in teeth that were caries-free or unerupted at baseline, as compared with 44% in the test group, a significant reduction (P = 0.021). The odds of new caries experience occurring were reduced by 51% in the DR-BNI group as compared with control. There was a 29% decrease in the relative risk of new caries experience in the DR-BNI group as compared with control. This single low-cost, low-intensity intervention was successful in significantly reducing the risk of recurrence of dental caries in children. This trial has implications for changing pediatric dental practice internationally. Training in and implementation of a motivational interviewing-informed brief intervention provides opportunities for dental nurses to facilitate behavior change improving the oral health of children at high caries risk (ISRCTN 24958829).

What the child "SAID" to the dentist: A UK randomized controlled trial

BACKGROUND

The electronic Survey of Anxiety and Information for Dentists (eSAID) allows children to tell dentists about their feelings and coping preferences. It is a computer "quiz" with 26 questions and free-text responses that produces a report for the children that they can then hand to their dentist. This is the first study to report the use of eSAID in a hospital paediatric dental clinic.

METHODS

This was a randomized controlled trial to evaluate whether children thought that eSAID benefitted them, made them less anxious, and improved cooperation and their treatment satisfaction. Fifty-one children aged 8-13 years were randomized to complete either eSAID or a control version in the waiting room before their scheduled dental appointment. The study group had a 26-item questionnaire; the control had only two items. Both groups scored their anxiety on a 7-point anxiety scale at the start and again at the end of the quiz. All subjects handed the resultant eSAID report as a printout to their dentist. Dental treatment proceeded as planned. After treatment, each child reported how they thought the eSAID quiz had benefitted them by scoring on a 10 cm Visual Analogue Scale and their satisfaction on the Modified Treatment Evaluation Inventory. The operating dentists scored the children's cooperation using a 10 cm Visual Analogue Scale.

RESULTS

Overall, the baseline anxiety levels were low (study: mean 1.2; control: mean 1.5). The study group's post-survey anxiety reduced by 0.4, whereas controls' increased by 0.2; this difference is statistically significant (p = .04). However, it made no difference to the children's self-reported benefit (p = .30), satisfaction (p > .05), or cooperation (p = .34).

CONCLUSIONS

eSAID reduced pre-treatment anxiety but made no difference to children's perceived benefit, satisfaction, or cooperation. Future study should include known anxious children.

Lessons learned on recruitment and retention in hard-to-reach families in a phase III randomised controlled trial of preparatory information for children undergoing general anaesthesia

BACKGROUND

Recruitment and retention are documented as two of the most difficult elements of conducting clinical trials. These issues are even more challenging in paediatric trials, particularly when the families being recruited and retained are deemed 'hard to reach'.

METHODS

Through the authors' own reflection on the conduct of the trial this paper examines recruitment and retention with hard to reach families from the perspective of a recently completed clinical trial on preparatory information for children undergoing general anaesthesia for tooth extractions in which approximately 83% of those approached and eligible agreed to participate.

RESULTS

The lessons learned for recruitment include: the importance of children's assent; maximising limited resources when screening and approaching potential participants; valuing families' time; and developing effective professional relationships. The retention rate was 83-85.5% at follow up time points up to 3.5 weeks following recruitment, insights into how this was accomplished include: ensuring continuity of care; determination to connect via telephone; valuing families' time; and close monitoring of appointment date changes.

CONCLUSIONS

Implications for future paediatric trials with hard to reach families are discussed.

TRIAL REGISTRATION

ISRCTN18265148 ; NIHR Portfolio 10,006. Date of Registration: 29 November 2013. The trial was registered after commencement but before completion of data collection.

What preventive care do sedated children with caries referred to specialist services need?

Introduction Few studies have assessed the preventive needs of children treated under conscious sedation or their parents'/guardians' views regarding oral health education.Aim To report on the profile of children who required treatment under conscious sedation. Also to obtain the views of the parents or guardians of these children on their experiences of oral health preventive services and the support they would like in order to improve their child's oral health.Method A researcher-administered questionnaire was used to collect quantitative and qualitative responses from a consecutive sample of 123 parents/guardians during their child's sedation appointment at King's College Hospital.Results Caries was the main reason for the child's sedation treatment and 77.2% of them were high caries risk. Parents reported that their general dentist had given advice about sugar (80%) and tooth-brushing (74%), but few had prescribed fluoride varnish (15%), fissure sealants (12%) or a fluoride rinse (36%). Parents felt challenged by the ready availability of sugar, and others suggested difficulty in maintaining healthy oral habits in complex families. Overall, the majority of parents thought leaflets, health professionals' advice, and Internet websites could be informative, and they requested school- and hospital-based prevention programmes.Discussion The majority of children had high caries risk. They had received advice but not professional preventive treatment such as fluoride varnish and fissure sealants. Their parents requested preventive education using new technologies and media and better access through school-based and hospital prevention programmes.

Parental views on delivering preventive advice to children referred for treatment of dental caries under general anaesthesia: a qualitative investigation

OBJECTIVES

To: 1, Explore opinions of parents of children undergoing caries treatment under general anaesthesia (GA) regarding delivery of oral health advice; 2, Discover current oral health practices and beliefs; 3, Inform further research and action.

METHODS

Qualitative study using semi-structured interviews and thematic data analysis, sampling parents of children aged 3-10 years undergoing GA tooth extraction due to dental caries.

RESULTS

Twenty nine parents were interviewed (mean age 38.9 years, range 28-50, sd 6.4). The mean age of their children was seven years (range 3-10, sd 2.1). All children required deciduous tooth extractions (5.1 teeth on average). Those that also required permanent tooth extractions had on average 2.1 permanent teeth extracted. Many parents knew the importance of oral hygiene and sugar limitation, describing it as 'general knowledge' and 'common sense'. However, few understood that fruit juice is potentially cariogenic. Parenting challenges seemed to restrict their ability to control the child's diet and establish oral hygiene. Many reported not previously receiving oral health advice and reported never having fluoride varnish applied. There were requests for more caries prevention information and advice via the internet, schools or video games.

CONCLUSION

Parental oral health knowledge, parenting skills, and previous advice received seem to all be issues related to the oral health of those children. Providing advice, especially in respect to fruit juice cariogenicity and the benefits of fluoride application through a child-friendly website, including a video game, as well as the use of school programmes might be an acceptable approach.

An inhalation sedation patient profile at a specialist paediatric dentistry unit: a retrospective survey

AIM

To report on the characteristics, treatment, attendance, scheduling and duration of treatment sessions of child patients attending a specialist paediatric dental hospital service for inhalation sedation.

METHODS

A retrospective study was carried out of all 88 patient case notes of inhalation sedation recipients between September 2004 and March 2005. The recorded data included: child's age, gender and level of social deprivation together with the details of the treatment that was undertaken, the time between the first and current/last sedation appointment and the total number of appointments attended, cancelled and missed.

RESULTS

Twenty of the subjects were excluded giving a sample of 68; 51% male, mean age at start of treatment 9.8 years (range 4 to 15) and mean age at end of treatment 10.6 years (range 4 to 16). Of these children 35 (51%) were socially deprived. In respect to treatment, 29% had extractions, 22% endodontics, 81% restorations and 25% fissure sealants. In respect to the number of quadrants that had teeth requiring treatment; 26.5% had one, 25% two, 22% three and 26.5% four. The mean number of treatment sessions required was 4.4 with a mean duration between first and last appointments of 9.5 months (range 0.25 051). There were 27% of appointments cancelled, while 12% of patients failed to keep their appointments.

CONCLUSIONS

Although over half of the children treated under inhalation sedation came from socially deprived areas, attendance was reasonable and the majority required less than 5 appointments for treatment completion. The treatment provided was variable not only in respect to the procedures but also to the number of quadrants treated.

Contemporary dental practice in the UK in 2008: aspects of direct restorations, endodontics and bleaching

OBJECTIVE

To investigate, by postal questionnaire, aspects of the selection and use of direct restorative materials, endodontic techniques and approaches to bleaching by general dental practitioners in the UK, and to compare and contrast the findings with those of a related study reported in 2004.

METHODS

A questionnaire comprising 18 questions, each of a number of elements, was sent to 1,000 general dental practitioners in the UK, selected at random from the Dentists Register. Non-responders were sent a second copy of the questionnaire after a period of four weeks had elapsed.

RESULTS

A total of 662 useable responses were returned, giving a response rate of 66%. Key findings included: dental amalgam was found to be the most commonly used material in the restoration of occlusoproximal cavities in premolar (59% of respondents) and molar teeth (75% of respondents); glass-ionomer cements and related materials were applied extensively in the restoration of deciduous molars (81% of respondents) and for the luting of indirect restorations (67% of respondents); the use of rubber dam was limited, in particular as an adjunct to procedures in operative dentistry (18% of respondents); relatively few respondents used preformed stainless steel crowns, and among the users only occasionally in the restoration of deciduous molars (23%); and bleaching, predominantly home-based (nightguard) vital bleaching (81% of respondents) was widely practised.

CONCLUSION

It is concluded that, for the practitioners surveyed, factors other than best available evidence influenced various aspects of the use of direct restorative materials and the clinical practice of endodontics. As a consequence, many of the features of general dental practice revealed in the process of the investigation were at variance with teaching in dental schools. Bleaching, in particular home-based (nightguard), vital bleaching, was provided by >80% of respondents, indicating widespread interest among patients in enhanced dental attractiveness.

The effect of transmucosal 0.2 mg/kg midazolam premedication on dental anxiety, anaesthetic induction and psychological morbidity in children undergoing general anaesthesia for tooth extraction

BACKGROUND

The project aims were to evaluate the benefit of transmucosal midazolam 0.2 mg/kg pre-medication on anxiety, induction behaviour and psychological morbidity in children undergoing general anaesthesia (GA) extractions.

METHOD

One hundred and seventy-nine children aged 5-10 years (mean 6.53 years) participated in this randomised, double blind, placebo-controlled trial. Ninety children had midazolam placed in the buccal pouch. Dental anxiety was recorded preoperatively and 48 hours later using a child reported MCDAS-FIS scale. Behaviour at anaesthetic induction was recorded and psychological morbidity was scored by the parent using the Rutter Scale preoperatively and again one week later. Subsequent dental attendance was recorded at one, three and six months after GA.

RESULTS

While levels of dental anxiety did not reduce overall, the most anxious patients demonstrated a reduction in anxiety after receiving midazolam premedication (p = 0.01). Neither induction behaviour nor psychological morbidity improved. Irrespective of group, parents reported less hyperactive (p = 0.002) and more pro-social behaviour (p = 0.002) after the procedure; older children improved most (p = 0.048). Post-GA dental attendance was poor and unaffected by premedication.

CONCLUSION

0.2 mg/kg buccal midazolam provided some evidence for reducing anxiety in the most dentally anxious patients. However, induction behaviour, psychological morbidity and subsequent dental attendance were not found to alter.

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

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

A report on dental anxiety levels in children undergoing nitrous oxide inhalation sedation and propofol target controlled infusion intravenous sedation

AIM

To report on two separate child sedation cohorts; one undergoing propofol intravenous sedation (IVS) and the other, nitrous oxide inhalation sedation (IS) in respect to changes in dental anxiety and subject characteristics.

STUDY DESIGN

The age, gender, level of social deprivation and amount of treatment performed and observed patient behaviour during treatment, using the Frankl and a VAS scale, were recorded for each subject. Anxiety questionnaires were completed before and after treatment. These were: - Modified Child Dental Anxiety Scale (MCDAS); Children's Fear Survey Schedule- Dental Subscale (CFSS-DS) and two Visual Analogue Scales (VAS).

RESULTS AND STATISTICS

Participants (36) attended for treatment under IS and 40 attended for treatment under propofol IVS. The IVS cohort was older (p<0.01), by between 1.9 and 4.1 years and had more treatment [p = 0.015, 95% confidence interval for the difference between the cohort medians was (0, 3) units]. The two cohorts were closely matched in respect to pre-operative anxiety as measured by the MCDAS and CFSS-DS scales. There were significant anxiety reductions within each cohort as measured by three of the scales: - MCDAS, CFSS-DS and VAS (1) (p< or = 0.001) but no significant change in the VAS (2) scores. When the two cohorts were compared, there was no significant difference in the reduction of the self-reported anxiety for any of the four scales (p>0.05). The observed behaviour was good for both cohorts.

CONCLUSION

Propofol target-controlled intravenous sedation and nitrous oxide inhalation sedation were similarly efficacious at anxiety reduction in referred dentally anxious children. Subjects undergoing propofol IVS were older than those undergoing IS. Propofol TCI may offer the opportunity for more treatment at each visit. Further propofol TCI conscious sedation studies are required.

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

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

The behaviour, social status and number of teeth extracted in children under general anaesthesia: A referral centre revisited

OBJECTIVE

To report on the changing profile of children attending for Dental General Anaesthetic extractions (DGA) at the same centre in 1998 and again in 2004 compared to 1991.

DESIGN

Prospective clinical.

SETTING

Glasgow Dental Hospital DGA service during August 1999 and August/September 2004.

SUBJECTS AND METHOD

Children presenting for DGA extractions. Data recorded: age, gender, number of teeth extracted and level of behaviour using the Frankl scale.

RESULTS

In 1999: 190 children (97 boys) mean age five years. In 2004: 106 children (55 boys) mean age five years. There was a significant increase in the mean number of teeth extracted (p < 0.001), 4.2 (1-16) and 7.8 (1-17) in 1999 and 2004 respectively, compared to 3.7 in 1991. Twenty-six per cent of children had between six and 16 teeth extracted in 1999 compared to 74% in 2004. Significantly fewer children demonstrated "definitely positive" behaviour compared to 1991. Children were in the poorest socioeconomic groups, reflecting the geographic area.

CONCLUSION

Over half of the children were aged five years and under. Fewer highly co-operative children were treated. More teeth were extracted per child, suggesting that there should be greater opportunities to carry out restorations, not just extractions under general anaesthesia.

Dental anxiety, distress at induction and postoperative morbidity in children undergoing tooth extraction using general anaesthesia

OBJECTIVE

To report on the prevalence of postoperative morbidity in children undergoing tooth extraction under chair dental general anaesthetic (CDGA) in relation to pre-operative dental anxiety and anaesthetic induction distress.

DESIGN

A prospective national study.

SETTING

Twenty-five Scottish DGA centres in 2001.

SUBJECTS AND METHOD

Four hundred and seven children (mean age 6.6 years; range: 2.3 to 14.8 years; 52% male). Before CDGA, the Modified Child Dental Anxiety (MCDAS) and Modified Dental Anxiety (MDAS) Scales were completed for children and accompanying adult respectively; the latter also returned a morbidity questionnaire 24 hours and one week post-operatively. Anaesthetic induction distress was scored immediately before CDGA induction using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS).

RESULTS

The mean MCDAS score was 24.2 (population norm 18.2); 21% of adults were anxious. Forty-two per cent of children had induction distress; this related to their MCDAS scores (r=0.43, p<0.001, Pearson Product Moment Correlation Coefficient). Morbidity at 24 hours and seven days was 63% and 24% respectively; this related to MCDAS scores (r=0.15, p=0.029 and r=0.17, p=0.009, Pearson Product Moment Correlation Coefficient) and to induction distress (chi2=7.14, p=0.007 and chi2=11.70, p=0.001).

CONCLUSION

The majority of children suffered next day morbidity and many still had symptoms a week later. Most children were dentally anxious; this related to induction distress and postoperative morbidity.

Dental follicle infection following a dog bite

Animal bite wounds and their subsequent infection are relatively common. Incidence rates for dog bites are significantly higher among children aged 0-9 years, especially among boys. Although bite wounds may initially look innocuous, they frequently lead to serious infection with a potential for life-threatening complications. The microbiology of dog bite wounds is usually polymicrobial, typically including anaerobes, Staphylococcus aureus and Pasteurella species. A case is described of a 22-month-old boy who, subsequent to a dog bite over the left maxilla, suffered infection of the dental follicle of the primary maxillary canine with Pasteurella multocida. The infection proved difficult to treat, requiring several attempts at incision and drainage of the abscess together with systemic antibiotics, and resulted in the eventual loss of the tooth.

Factors influencing referral of children for dental extractions under general and local anaesthesia

OBJECTIVE

To investigate the relative importance of a range of explanatory variables concerning why child patients in Scotland enter pathways for tooth extractions under either Dental General Anaesthesia (DGA) or local anaesthesia (LA).

BASIC RESEARCH DESIGN

A cross-sectional study was carried out involving DGA centres across Scotland. Data collected related to demographic characteristics of child DGA patients, reported anxiety and dental attendance levels of patients and parents, reasons given by referring practitioners for requesting DGA, number and type of teeth extracted and parental beliefs and attitudes to DGA. Similar data were collected relating to children having teeth extracted in primary care under LA. Multivariate analysis was performed to determine which factors were the best predictors of anaesthetic choice.

RESULTS

425 and 121 children having dental extractions under DGA and LA respectively participated. Ninety-six percent of DGA cases and 48% of LA patients had extractions for caries. For DGA cases, the mean age was 6.7 years, an average of 5.3 teeth were extracted and dental anxiety levels were higher than population norms. Multivariate analysis found the number of teeth extracted was the major predictor of anaesthetic type. On removing this variable, age became the most important factor, with 99% of children under 5.5 years receiving a DGA. Among DGA patients, 25% were reported to have had a previous DGA for tooth extraction.

CONCLUSIONS

Future reductions in DGA numbers will be dependent on decreasing the number of young children presenting with advanced caries in multiple teeth. Consequently, guidelines are required concerning the prevention and appropriate management of caries in the primary dentition.

Cyclosporin-induced gingival overgrowth in children

Cyclosporin is a potent immunosuppressant drug commonly used to prevent organ transplant rejection. In recent years, there has been a widening of its therapeutic use and an increase in the number of patients undergoing transplantation. Gingival overgrowth is one of several oral side-effects of cyclosporin, with a quoted prevalence of between 8% and 100%. There is continued debate over the factors which modify the degree of overgrowth, including individual sensitivity, age, dose of drug, duration of drug therapy and the presence of dental plaque. The exact mechanism of gingival overgrowth is still being debated, but appears to be caused by a combination of the proliferation of fibroblasts within the gingival tissue, an increase in the deposition of collagen and extracellular matrix, and a decrease in phagocytosis with a net gain in gingival tissue mass. A number of treatment options are utilized in the treatment of gingival overgrowth, including CO2 laser surgery, improved oral hygiene, the use of antibiotics such as metronidazole and azithromycin, and surgical intervention. In the clinical application of cyclosporin, there is little correlation between cyclosporin dose, serum trough levels and total exposure to the drug, making it difficult to achieve the desired therapeutic response. These problems were previously further complicated by the variability of absorption of the drug via the gastrointestinal tract. The original cyclosporin formulation, Sandimmune, was replaced by a new formulation, Neoral, which has a more reliable absorption, and gives a closer correlation between trough concentration levels and individual bioavailability. There is a conflict of opinion over whether or not the side-effect profile of Neoral varies from its precursor Sandimmune. It has yet to be seen whether the increased bioavailability of Neoral will result in an increased severity and prevalence of gingival overgrowth. An alternative immunosuppressant drug, tacrolimus, which is a macrolide antibiotic with a different side-effect profile, has emerged as a substitute for cyclosporin in organ transplantation. However, there have been conflicting reports of its side-effects and its capacity to cause gingival overgrowth.

Facial characterization of infants with cleft lip and palate using a three-dimensional capture technique

OBJECTIVE

To characterize the soft tissue features of infants with unilateral cleft lip (UCL) and unilateral complete cleft lip and palate (UCLP) prior to primary surgery and compare with noncleft controls.

DESIGN

Prospective controlled capture of the facial morphology of infants using a noninvasive three-dimensional stereophotogrammetry method.

PARTICIPANTS

23 children with presurgical cleft: 11 UCL (M = 6, F = 5); 12 UCLP (M = 9, F = 3), and 21 noncleft controls (M = 7, F = 14) were imaged at approximately 3 months of age (range 10 to 16 weeks).

MAIN OUTCOME MEASURE

Accurate, repeatable quantification of facial soft tissues in infants with clefts prior to surgery.

RESULTS

Significant differences (p <.05) were found between the UCLP group and UCL and control groups in anatomical and soft nose width, cleft-side alar wing length, and nasal tip horizontal displacement. Both cleft groups were significantly different from controls and from each other in cleft-side nostril dimensions, alar wing angulation, columella angle, and alar base to corner of mouth dimension; alar base width; and soft tissue defect in nose and the lip and philtrum length bordering the cleft. Significant differences between clefts and controls were identified in the nostril and philtrum on the noncleft side.

CONCLUSIONS

The use of children with UCL as controls for UCLP studies is inappropriate. This technique overcame the limitations of direct measurement of infant faces to aid the surgeon in the planning and subsequent re-evaluation of surgical rationale.

Propofol intravenous conscious sedation for anxious children in a specialist paediatric dentistry unit

OBJECTIVES

To report on both the use and dosage of propofol, as a new intravenous (IV) conscious sedative agent, for anxious children referred to a specialist paediatric dentistry service.

SETTING

Paediatric Dentistry Unit, Glasgow Dental Hospital and School.

SAMPLE

Thirty-four children, 25 females and 9 males, mean age 12 years 10 months, with a mean weight of 54.6 kg (range 30-110 kg).

METHODS

Report from 34 patients receiving intravenous sedation for the first time in respect of weight dose and amount of treatment completed.

RESULTS

Thirty-two children successfully accepted operative dental care on their first visit, they received a mean total dose of 146.25 mg of propofol (range 10 mg to 356 mg); in relation to body weight, the mean was 2.5 mg/kg (range 0.2-5.4 mg/kg). The treatment that they received included fissure sealants, amalgam and adhesive restorations, root canal therapy and single and multiple extractions. Their sedation and recovery were uneventful.

CONCLUSIONS

Sub-anaesthetic doses of propofol used for IV conscious sedation infusion facilitated operative dental treatment in anxious children.

Facial asymmetry--3D assessment of infants with cleft lip & palate

OBJECTIVES

To determine the degree of facial asymmetry in infants with unilateral cleft lip and/or palate, and quantify improvements following primary surgery, in three dimensions.

DESIGN

The faces of 20 infants with unilateral clefts (10 UCL; 10 UCLP), and 20 age-matched, non-cleft controls, were captured using the C3D stereophotogrammetry system prior to primary lip/nose repair (at 3 months), at 6 months and at age 1 year.

METHODS

Procrustes techniques were applied to 3D landmark configurations to its mirror image. Mean squared distances between landmarks and their antimeres were calculated and expressed as asymmetry scores for each 3D configuration. Full-face, nose and lip median scores were compared and changes with time evaluated (P < 0.01).

RESULTS

There were no significant changes in asymmetry scores in the control group from 3 months to 1 year. The UCLP group was more asymmetric than the UCL group, displaying greatest improvement in nasal symmetry following primary repair. The lips continued to improve over time. The UCL group had significant nasal asymmetry, which did not appear to improve with primary surgery.

CONCLUSIONS

Immediate improvement in asymmetry scores in children with UCLP is related to the production of a more symmetrical nasal form after primary surgery. In contrast, the nasal asymmetry seen in children with UCL is unchanged despite surgery. Full face asymmetry scores may mask subtle changes over time. Nasal and lip asymmetry should be considered individually.

Multiple dens invaginatus in two brothers

Dens invaginatus is a developmental variation resulting from an alteration in the normal growth pattern of the dental papilla of a tooth. They predominantly occur on maxillary permanent lateral incisors. Their occurrence in several maxillary incisor teeth in an individual has been frequently reported, and the examination of bilateral teeth for the anomaly is well accepted. However, the present case illustrates the importance of examining both maxillary and mandibular incisors in patients who present with a dens invaginatus, in addition to other members of the family.

A review of correspondence to a general dental practice 'helpline'

The aim of this retrospective study was to examine the correspondence sent to a dental helpline. A general dental practice telephone helpline was established under the auspices of the British Dental Health Foundation (BDHF). The name and contact telephone number were provided via the BDHF or through various media and patient organisations such as the Phobic Society. All the telephone enquirers were encouraged to follow up their telephone call with a written letter. The contents of the 105 letters which were received over a four-year period were collated and categorised. Correspondents fell into two categories: those seeking information about various dental issues and those who described themselves as dental phobics. There were 64 requests for information; of these, 20 were straightforward requests for information booklets, 16 were complaints about denture problems and 10 wanted advice on finding a 'sympathetic' dentist. 'Dental phobics' was how 41 correspondents described themselves. Seven of these 'dental phobics' wrote that they perceived their dental state to have become so poor that they were too embarrassed to attend a dentist. In conclusion, this pilot study highlights the potential value of a helpline in a general dental practice setting and describes the scope of enquiries received. The findings will help general dental practitioners who may wish to use a dental helpline to improve patient access to primary dental care.

An evaluation of four methods of assessing the behaviour of anxious child dental patients

The aim of this study was to evaluate four behavioural scales which have been used to assess anxious children during dental treatment: The Frankl (F), Houpt (H), Visual Analogue (VAS) and Global Rating (GR) scales. The study measured the agreement on three of the scales (F, H and VAS) between two judges expert in the management of anxious children and also between four other dentists. The operating dentists scored each visit using the fourth scale (GR). Twenty-nine anxious children aged 3-16 years who had been referred to a specialist clinic were included in the study, and 64 separate visits were recorded on videotape. The two-judge panel evaluated the children's behaviour on all 64 visits, and the four-judge panel evaluated a 12-visit segment. Comparisons within and between the two-judge and four-judge panels showed close agreement on the Visual Analogue and Houpt scales but not on the Frankl scale. There was significant correlation between the Global Rating scale and the Visual Analogue, Houpt and Frankl scales.

Anxious children: coping in dental practice

Treating anxious children is a challenge that many dentists face. Not only do anxious children find it difficult to cope with dental treatment but dentists also find it difficult to cope with anxious children. This article is intended to simplify the management of anxious children in general dental practice. Behavioural management, the coordination of the whole dental team, treatment planning and the use of inhalation sedation will be discussed.

Oral findings in children with liver transplants

A report is presented of a prospective study into the oral manifestations of liver disease in children. Fifty-five children who had received a liver transplant were examined; their ages ranged from 8 months to 16 years 2 months, and 37 of them were under 5 years of age. The following information was noted: the teeth that were erupted, the presence and severity of enamel hypoplasia and of gingival hyperplasia, and the presence of intrinsic discoloration. Results showed that seven of the 17 children under 3 years of age had delayed eruption of teeth. Six children had enamel hypoplasia, three in permanent incisors and three in primary incisors. Intrinsic discoloration was found in the primary dentition of 25 children (23 of whom had biliary atresia prior to receiving the transplant) and in one child's permanent incisors. Thirty-four children had gingival hyperplasia. There was a significant inverse relationship between the length of time since transplantation and the severity of gingival hyperplasia. Analysis of variance failed to show any association between serum cyclosporin levels and the severity of gingival hyperplasia. There was no significant relationship between current nifedipine medication and the presence of gingival hyperplasia.