1. www.dentalnews.com Volume XVI, Number III, 2009
Endodontic
surgery versus
retreatment
CLEFT LIPS
AND PALATES
ISSN 1026 261X
25 Anniversary
th
School of Dentistry
Lebanese University

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5. CONTENTS
Vo l u m e X V I , N u m b e r I I I , 2 0 0 9
EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury,
Dona Raad, Antoine Saadé, Lina Chamseddine,
13 Adopting minimum intervention
Tarek Kotob, Mohammed Rifai, Bilal Koleilat, in dentistry
Mohammad H. Al-Jammaz Dr. Steffen Mickenautsch
COORDINATOR Lina Jadaa
ART DEPARTMENT Krystel Kouyoumdjis 20 Cleft lips and palates
SUBSCRIPTION Micheline Assaf, Nariman Nehmeh
Dr. Abu-Hussein Muhamad
ADVERTISING Josiane Younes
PHOTOGRAPHY Albert Saykali
TRANSLATION Gisèle Wakim, Marielle Khoury 28 Lumineers
DIRECTOR Tony Dib Dr. David Silber
ISSN 1026-261X
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INTERNATIONAL REVIEW BOARD
Pr. M.A. Bassiouny BDS, DMD, MSc, Ph.D. Director International Program, Temple University, Philadelphia, USA.
36 Endodontic surgery versus retreatment
Pr. N.F. Bissada D.D.S., M.S.D Professor and Chairman, Department of Periodontics, Case Western Reserve Dr. Richard Mounce
University, USA.
Pr. Jean-Louis Brouillet D.C.D, D.S.O. Chairman, Department of Restorative Dentistry, Aix-Marseille II, France. 54 25th Anniversary - School of Dentistry
Pierre Colon D.C.D., D.S.O. Maître de conférence des universités, Paris, France. Lebanese University
Dr. Jean-Claude Franquin, Directeur de l’Unité de Recherche ER116, Marseille, France.
Pr. Gilles Koubi D.C.D., D.S.O. Department of Restorative Dentistry, Aix-Marseille II, France.
Pr. Guido Goracci. University LA SAPIENZA, School of Medicine & Dentistry, Roma, Italia.
Dr. Olivier Hue, Faculté de chirurgie dentaire de Paris VII, rue Garancière, Paris, France.
Brian J. Millar BDS, FDSRCS, Ph.D. Guy’s, King’s, and St. Thomas’ College School of Medecine & Dentistry,
London, UK.
Pr. Dr. Klaus Ott, Director of the Clinics of Westfälischen Wilhelms-University, Münster, Germany.
Wilhelm-Joseph Pertot DEA, Maître de conférence, Aix-Marseille II, France.
Pr. James L. Gutmann, Professor and Director, Graduate Endodontics, Baylor College of Dentistry, Dallas, Texas,
USA.
Pr. Dr. Alfred Renk, Bayerische Julius-Maximilians-University, Würzburg, Germany.
Dr. Philippe Roche-Poggi DEA. Maître de conférence des universités, Aix-Marseille II, France.
Michel Sixou D.C.D., D.E.A. Department of Priodontology, Toulouse, France.
3 Contents
Pr. M. Sharawy B.D.S., Ph.D. Professor and Director, Department of Oral biology, Medical College of Georgia,
Augusta, Georgia, USA.
DENTAL NEWS IS A QUARTERLY MAGAZINE
DISTRIBUTED MAINLY IN
THE MIDDLE EAST & NORTH AFRICA
IN COLLABORATION WITH
THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC.
Statements and opinions expressed in the articles
and communications herein are those of the author(s) and
not necessarily those of the Editor(s) or publisher. No part of
this magazine may be reproduced in any form, either electronic or 72 Product Review
mechanical, without the express written permission of the publisher.

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13. INTERNATIONAL CALENDAR
September 23–26, 2009
The Beirut International Dental Meeting 2009 November 6 - 7, 2009
Congress Palace Dbayeh 1st Dental – Facial Cosmetic International Conference
Contact: Dr. Antoine Karam, President of the Lebanese Dental Association Where Science Meets Art of Beauty
Email: lda@lda.org.lb Jumeirah Beach Hotel UAE
Website: www.LDA.org.lb Email: info@cappmea.com
Website: http://www.cappmea.com
October 14–16, 2009
The 17th Scientific International Conference of Syrian Dental Association, November 10 - 12, 2009
Damascus Ommayad Palace for conferences, Damascus Ebla Hotel 1st Dubai International Implant Summit
Contact: Syrian Dental Association, Damascus, Syria, POB: 11104 Crowne Plaza Dubai - UAE
Tel: 963 11 222 1446 – Fax: 963 11 222 48 45 Email: matios.tcholakian@index.ae
Email: syrdent@scs-net.org Website: http://www.diis.ae
Website: http://www.syr-sda.com
November 10 - 12, 2009
October 15 - 17, 2009 DENTISTRY 2009
37th International Expodental Rome ADNEC, Abu Dhabi – UAE
Pavilions 7-8-9 of the new Fiera Roma Exhibition Center Email: dentistry@iirme.com
Email: pressoffice@expodental.it Website: http://www.dentistryme.com
Website: http:// www.expodental.it
November 11 - 13, 2009
October 21 - 23, 2009 Egyptian Dental Association – 14th International Dental Congress
The 4th Riyadh International Pharmacy Meeting - 4th RIDPM Problem solving in Dentistry
Riyadh, Saudi Arabia from October 21st to 23rd, 2009 [02-04/10/1430]. Intercontinental Hotel - Cairo - City Stars
Email: meeting@riyadh.edu.sa Email: eda@internetegypt.com.eg
Website: http://riyadh.edu.sa/meeting Website: http;//www.eda-egypt.org
October 27 - 29, 2009 November 29 – December 2nd, 2009
The 5th Bahrain Dental Society Conference 2009 Greater New York Dental Meeting
27- 29 October 2009 Tel: 212-398-6922
Email: bahds@batelco.com.bh Fax: 212-398-6934
Website: http://www.bahrain-dental.com Email: info@gnydm.com
Website: http://www.gnydm.com
November 3 - 6, 2009
1st Pan Arab Endodontic conference March 9 - March 11, 2010
LandMark Hotel (RadissonSAS) Amman, Jordan AEEDC Dubai
Dr. Ibrahim Abu Tahun Dubai International Convention & Exhibition Centre
Email: ihtahun@yahoo.com Email: index@emirates.net.ae
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Volume XVI, Number III, 2009
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DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

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15. OPERATIVE DENTISTRY
Adopting minimum intervention in dentistry:
Diffusion, bias and the role of scientific evidence
Dr S Mickenautsch, BDS, PhD
Division of Public Oral Health, University of the Witwatersrand, 7 York Rd, 2193
Parktown/Johannesburg, South Africa
Email: neem@global.co.za
Abstract provider to advise healthy patients about their risks regarding
Minimum Intervention (MI) in dentistry aims to empower possible future ailments11. Such risks may be due to aspects related
patients through information, skills, and motivation to take to a patient's lifestyle or to other factors with the potential to
charge of their own oral health and consequently require only have an impact upon health12. These aspects are then assessed
minimum intervention from the dental profession. Although MI to determine the basis on which addressing the identified risk
in dentistry has until now focused mainly on caries-related topics, factors with targeted prevention is possible13.
it follows the 3-step philosophy of disease risk assessment, early Patients with manifest disease are helped by as early as possible
disease detection and, if required, minimally invasive treatment. identification of such manifestation14-16. As disease at an early
This philosophy is applicable to any type of disease. The subsequent stage is often relatively contained, treatment can consequently
benefit of MI is its focus on disease causes and ultra-conservative, be simple, very conservative and minimally invasive1.
patient-friendly treatment. Successful diffusion of MI depends Laboratory findings, clinical considerations and protocols, materials
on substantiation of its beneficial claims through low-bias evidence. and technologies for all three steps of MI in dentistry have been
13 Adopting minimum intervention in dentistry
Such evidence provides the first step for a wider adoption which, reported elsewhere3-6,17. Patients benefit from MI because of its
furthermore, depends on complex factors related to adopter focus on the cause of disease instead of on merely addressing
behavior. disease symptoms7. A further benefit for patients is its patient-
friendly nature, due to its minimally invasive treatment options.
Introduction MI procedures are considered to be atraumatic, since patients
Since the beginning of this millennium information about the experience less discomfort and pain than traditional treatment
procedures and benefits of minimum intervention, an innovative, options incur8. Experience and expectation of pain and discomfort
modern healthcare approach for dentistry, has been increasingly during dental treatment has been associated with dental fear18.
disseminated1-8. As with any innovation, wide adoption of minimum A study investigating the dental fear levels of children and adults
intervention by the dental profession is reliant upon factors related during atraumatic restorative treatment (ART), in comparison to
to the process of diffusion9. This paper aims to contribute to the those receiving traditional restorative treatment using high-speed
discussion of this topic by highlighting the role, which both bias drilling, found patients treated with ART to be significantly less
and scientific evidence can play in this process. fearful than the others19. Patients with low levels of dental fear
are more cooperative during treatment than those with high fear
Minimum intervention levels20. Positive patient attitude and cooperation resulting from
Minimum Intervention (MI) in dentistry aims to empower reduction of fear during treatment sessions may further benefit
patients, through information, skills and motivation, to take the healthcare provider, as a direct correlation between dental
charge of their own oral health in order to require only minimum fear and operator stress in daily dental practice has been
intervention from the dental profession (Hien Ngo, National observed21.
University of Singapore; oral communication, September 2004). The MI benefits for patients, attributable to addressing causes
Although the focus of MI in dentistry has so far been on caries- of disease and to the reduced discomfort, and the benefits for
related topics10, the approach follows the 3-step philosophy of healthcare providers, resulting from stress reduction through
disease risk assessment; early disease detection and possible reduced patient fear and consequent higher patient coopera-
minimally invasive subsequent treatment. Such philosophy is tion, have been stated as reasons for adopting MI into daily
applicable to any type of disease2. MI enables the healthcare dental practice.
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

16. OPERATIVE DENTISTRY
Diffusion of innovation attrition bias (Table 1) 24.
Despite its stated benefits the still new philosophy of MI faces, Bias may affect studies by causing either an over-or under estimation
as most innovations commonly do, the process of diffusion. of the treatment effect of an investigated clinical procedure. This
Rogers9 (2003) defined “innovation” as an idea, practice or may lead to a situation where a new ineffective treatment procedure
object that is perceived as new, and “diffusion” as the process is presented as effective or an effective treatment is presented as
through which innovation spreads. Diffusion comprises (i) innovation ineffective. The overestimation of a treatment effect through
itself; (ii) the type and availability of channels through which the bias has been observed to be the most common25, thus providing
innovation is communicated to others; (iii) time and (iv) the the rationale for late adopters to doubt superiority claims at the
prevailing social system9. onset. Schulz et al. (1995) reported a 41% treatment effect over-
The social system constitutes the community of potential adopters estimation due to selection bias alone26. Such overestimation
of innovation, categorized as follows: the innovators themselves, would mean that a study comparing the treatment effect of a
early adaptors, early majority, late majority and laggards9. Rogers new clinical procedure against a standard one would report a
(2003) estimated the percentage distribution of these groups as Risk ratio (RR) of 0.82 while the true RR would only be 1.13. The
being 2.5%, 3.5%, 34%, 34% and 16%, respectively9. Except term “Risk” (R) describes the number of patients having an
for the innovators themselves, these adopter groups' responses event (e.g. remaining ill after treatment) (nill) divided by the total
to innovation can vary between adoption, non-adoption or number of patients treated (ntotal)27.
rejection22. An innovation is considered self-sustaining once it R = nill : ntotal
has been accepted by 10-20% of all potential adopters9. As well If the effect of treatment with a new procedure is compared
as adoption of an effective innovation, rejection and resistance with the effect of a conventional, standard procedure, a “Risk
against such an innovation are possible. ratio” (RR) can be calculated by dividing the patient Risk of
remaining ill after treatment with the new procedure (Rnew) by
Research bias the patient Risk of remaining ill after treatment with the standard
One of the factors governing the response to an innovation by procedure (Rold)28.
potential adopters is insecurity concerning uncertainties about RR = Rnew : Rold
the advantages of new ideas, practices or objects as compared The so calculated RR indicates whether treatment with the new
to those of current ones22. Doubts regarding claims of superiori- procedure, in comparison to treatment with the standard procedure,
ty of, for example, new products or clinical procedures are justi- increases or decreases the risk (or chance) that patients may
14 Adopting minimum intervention in dentistry
fied if these are based on studies containing high degrees of bias remain ill28 . A presented RR of 0.82 would imply that the new
or systematic error. Bias has been defined as “any process at any procedure has reduced the chance of remaining ill for 18% of
stage of inference tending to produce results that differ system- patients. (A risk ratio of 1.00 would indicate no difference in risk
atically from the true values”23. The most important types of bias between the two procedures.) However, in a case of a 41%
in clinical studies are selection-, performance-, detection-and overestimation through bias, a real RR of 1.13 would mean that
Table 1. Types of bias in clinical trials
Bias Description
Selection bias New clinical procedures are usually tested in clinical trials consisting of 2 groups of patients: One group,
forming the control group, is treated with a conventional, most commonly used procedure being considered as
“currently accepted standard of care”. A second group (test group) is treated with the new procedure. At
the end of the study the success (or failure) rates of both procedures are compared. Selection bias occurs
when patients are selected into the 2 groups with known or unknown different characteristics. For example,
if patients in the test group have conditions, which favor the success of treatment and which are lacking
in patients of the control group then the new clinical procedure cannot be credited with the treatment
success43.
Performance bias Similar to selection bias, performance bias leads to wrong study results if the characteristics of patients in
one group of a clinical study support or hinder the treatment effect of a clinical procedure. However,
unlike in selection bias, performance bias is induced through active intervention, e.g. through additional
treatment during the study in preference to one group only44.
Detection bias Detection bias is created if the outcomes of both test-and control group are assessed differently. In other
words, if the outcome of one group is assessed more favorably then the other44.
Attrition bias Attrition bias occurs when patients allocated to either test-or control group are excluded from the outcomes
assessment. For example, if patients in the control group are excluded for whom the standard clinical procedure
lead to a treatment success. In such case the overall success rate of the standard treatment would be com-
parable lower than the new clinical procedure, thus falsely indicating that the later is superior24.
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

18. OPERATIVE DENTISTRY
Table 3 - Evidence hierarchy
the new procedure has in fact increased by 13% the chance of Study Design
patients' remaining ill. If such new clinical procedure were to be Highest evidence Large randomised trials with clear results
adopted into daily practice on the basis of the biased overesti- value / lowest bias Small randomised results with unclear results
mated results, then 13 out of 100 patients treated with the new COHORT studies
procedure would have been worse off than they would have Case-control studies
been if treated with the standard procedure. Case series and reports
Negative experiences of early adopters of an apparently ineffective
innovation, as shown in the example above, would in time lead to Lowest evidence Expert reports
value / highest bias
its rejection. Early adopters have been described as interacting more
frequently with peers than late adopters9. Therefore, negative expe- tion38. Nevertheless, diffusion of innovation is more likely if the
riences of an innovation by early adopters would be communicated evidence supporting it is regarded as being strong38,39.
to other adopter groups and this would prevent further diffusion. Furthermore, it has been observed that clinicians do recognize a
In that case, the critical mass of 10-20% of adopters29 would not hierarchy of evidence and most frequently regard randomized
be reached and the innovation would thus remain unsustainable. control trials (RCT) as the “gold standard”38. Locock et al. (1999)
described RCTs as providing the only form of evidence that may
Evidence and diffusion convince clinicians to adopt change40. Therefore strong evidence
To avoid negative feedback from early adopters during the diffu- is an important prerequisite for achieving wider adoption of an
sion process, an innovation needs to be based on low-bias innovation. Once strong positive evidence regarding an innova-
research because high internal validity of research provides the tion is available, further aspects of diffusion need to be consid-
prerequisite for the successful generalization and adoption of ered. These are related to complex factors of adopter behavior.
the innovation24 . Bias reduction in clinical studies focused on According to Morris et al. (1989), they may include past educa-
treatment is realized through a range of interventions (Table 2) tional and professional experiences, work environment and pro-
to be considered while planning and conducting a study24,29,30. fessional and personal aspirations41. Fitzgerald et al. (2002) add
In addition, it has been acknowledged that various study designs further considerations related to whether the innovation threat-
contain various degrees of bias31-33. For that reason an 'evidence ens the established skill base and, consequently, the status and
hierarchy' of study designs has been established (Table 3) 31-33. professional position of potential adopters, and to the impact of
It also has been recommended that once a study is conducted, financial incentives which may facilitate or inhibit adoption of an
16 Adopting minimum intervention in dentistry
its reporting should follow guidelines in order to assure recognition innovation42. The latter may be further reinforced by perceptions
of study quality34. Such guidelines include the CONSORT statement of potential adopters as to whether the innovation offers advan-
for randomized control trials35 and the STROBE statement for tages that the current methods do not22.
observational studies, such as Cohort and case-control studies36.
Studies with low bias are identified through systematic reviews, MI Evidence
using explicit, systematic methods designed to limit bias and the The need for strong (low-bias) evidence as an important prerequisite
chance effects37. Where possible the results of the identified for wide adoption of innovation38-40 applies also to MI. The Cochrane
studies are statistically combined, using META analysis and thus library (online: www.cochrane.org) and Midentistry's compendium
providing more precise estimates of healthcare effects37. database (online: www.midentistry.com/compendium.html) are
Despite the value of low-bias evidence, it has been shown that known sources for evidence generated through systematic
on its own this is not sufficient to facilitate diffusion of innova- reviews and META analysis and cover aspects of disease risk
Table 2. Bias-reducing interventions
assessment; early disease detection and minimally invasive treatment.
The compendium database follows Cochrane recommendations
Bias Intervention
and guidelines regarding the conduct of systematic reviews and
Selection bias (a) Selection of study subjects using a random allocation
sequence META analysis but focuses exclusively on MI topics, including disease
(b) Concealment of allocation sequence from investi- treatment and etiology, prognosis and diagnosis.
gators24
Conclusions
Performance bias Blinding (masking) of study subjects and care providers as
Minimum intervention (MI) in dentistry focuses on causes of dis-
to the differences per test-or control group24
ease and allows for ultra¬conservative treatment that is more
Detection bias Blinding (masking) of study assessors as to the differences patient-friendly than traditional dentistry. Successful diffusion of
per test-or control group24 MI requires substantiation of its beneficial claims through low-
bias evidence. Such evidence provides the first step for a wider
Attrition bias Inclusion of all randomized study subjects into the
adoption, which furthermore depends on complex factors of
analysis regardless of their adherence to the study
protocol, thus following “intention-to-treat” principle29,30 adopter behavior.
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

20. OPERATIVE DENTISTRY
REFERENCES
1. Frencken JE, Holmgren CJ. ART: A Minimal Intervention Approach To Manage 25. Chalmers TC, Matta RJ, Smith H Jr, Kunzler AM. Evidence Favoring The Use Of
Dental Caries. Dent Update 2004; 31: 295-301. Anticoagulants In The Hospital Phase Of Acute Myocardial Infarction. N Engl J Med
2. Mickenautsch S. An Introduction to Minimum Intervention Dentistry. Singapore 1977; 297: 1091-6.
Dent J 2005; 27: 1-6. 26. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical Evidence Of Bias:
3. Mount GJ, Ngo H. Minimal Intervention: A New Concept For Operative Dentistry. Dimensions Of Methodological Quality Associated With Estimates Of Treatment
Quintessence Int 2000; 31: 527-33. Effects In Controlled Trials. J Am Med Assoc 1995; 273: 408-12.
4. Mount GJ, Ngo H. Minimal Intervention: Early Lesions. Quintessence Int 2000; 27. The Cochrane collaboration. Cochrane Handbook For Systematic Reviews Of
31: 535-46. Interventions. Updated version 4.2.6; 2006. p. 102-103.
5. Mount GJ, Ngo H. Minimal Intervention: Advanced Lesions. Quintessence Int 28. The Cochrane collaboration. Cochrane Handbook For Systematic Reviews Of
2000; 31: 621-9. Interventions. Updated version 4.2.6; 2006. p. 103-105.
6. Murdoch-Kinch CA, McLean ME. Minimally Invasive Dentistry. J Am Dent Assoc. 29. May GS, Demets DL, Friedman LM, Furberg C, Passamani E. The Randomized
2003; 134: 87-95. Clinical Trial: Bias In Analysis. Circulation. 1981; 64: 669-73.
7. Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal Intervention Dentistry - 30. Sackett DL, Gent M. Controversy In Counting And Attributing Events In Clinical
A Review. Int Dent J 2000; 50: 1-12. Trials. N Engl J Med 1979; 301: 1410-2.
8. Whitehouse J. Minimally Invasive Dentistry. Clinical Applications. Dent Today 31. Cook DJ, Guyatt GH, Laupacis A, Sackett DL. Rules Of Evidence And Clinical
2004; 23: 56-61. Recommendations On The Use Of Antithrombotic Agents. Chest 1992; 102: 305S-
9. Rogers EM. Diffusion Of Innovation. 5th ed. New York: Free Press 2003. 311S.
10. World Dental Federation. Minimal Intervention In The Management Of Dental 32. Sackett D. Rules Of Evidence And Clinical Recommendations Can J Cardiol
Caries. FDI policy statement; 2002. 1993; 9: 487-9.
11. Sonbul H, Al-Otaibi M, Birkhed D. Risk Profile Of Adults With Several Dental 33. Woolf SH, Battista RN, Anderson GM, Logan AG, Wang E. Assessing The
Restorations Using The Cariogram Model. Acta Odontol Scand 2008; 66: 351-7. Clinical Effectiveness Of Preventive Manoeuvres: Analytic Principles And Systematic
12. Walsh LJ. Lifestyle impacts on oral health. In: Mount GJ, Hume WR, editors. Methods In Reviewing Evidence And Developing Clinical Practice
Preservation And Restoration Of Tooth Structure. Brighton: Knowledge books and Recommendations. A Report By The Canadian Task Force On The Periodic Health
software; 2005. p. 83-109. Examination. J Clin Epidemiol 1990; 43: 891-905.
13. Ngo HC, Gaffney S. Risk Assessment In The Diagnosis And Management Of 34. Moher D, Simera I, Schulz KF, Hoey J, Altman DG. Helping Editors, Peer
Caries. In: Mount GJ, Hume WR editors. Preservation and restoration of tooth Reviewers And Authors Improve The Clarity, Completeness And Transparency Of
structure. Brighton: Knowledge books and software; 2005. p. 61-82. Reporting Health Research. BMC Medicine 2008; 6:13.
14. Angmar-Månsson B, ten Bosch JJ. Quantitative Light-Induced Fluorescence 35. Moher D, Schulz KF, Altman DG. The CONSORT statement: Revised
(QLF): A Method For Assessment Of Incipient Caries Lesions. Dentomaxillofac Recommendations For Improving The Quality Of Reports Of Parallel-Group
Radiol 2001; 30: 298-307 Randomised Trials. Lancet 2001; 357: 1191-4.
15. Mendes FM, Nicolau J, Duarte DA. Evaluation Of The Effectiveness Of Laser 36. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP;
Fluorescence In Monitoring In Vitro Remineralization Of Incipient Caries Lesions In STROBE Initiative. The Strengthening the Reporting of Observational Studies in
Primary Teeth. Caries Res 2003; 37: 442-4. Epidemiology (STROBE) statement: guidelines for reporting observational studies.
16. Mendes FM, Sigueira WL, Mazzitelli JF, Pinheiro SL, Bengtson AL. Performance Bull World Health Organ 2007; 85: 867-72.
of DIAGNOdent For Detection And Quantification Of Smooth -Surface Caries In 37. The Cochrane collaboration. Cochrane Handbook For Systematic Reviews Of
Primary Teeth. J Dent 2005; 33: 79-84. Interventions. Updated version 4.2.6; 2006. p. 15.
17. Kitasako Y, Nakajima M, Foxton RM, Aoki K, Pereira PNR, Tagami J. 38. Dopson S, Fitzgerald L, Ferlie E, Gabbay J, Locock. No Magic Targets! Changing
Physiological Remineralization Of Artificial Demineralized Dentine Beneath Glass Clinical Practice To Become More Evidence Based. Health Care Manage Rev 2002;
Ionomer Cements With And Without Bacterial Contamination In Vivo. Oper Dent 27: 35-47.
2003; 28: 274-80. 39. Dopson S, Gabbay J, Locock L, Chambers D. Evaluation of the PACE pro-
18 Adopting minimum intervention in dentistry
18. Vassend O. Anxiety, Pain And Discomfort Associated With Dental Treatment. gramme: Final report. Southampton: Templeton College, University of Oxford and
Behav Res Thu 1993; 31: 659-66. Wessex Institute for Health Research and Development, University of
19. Mickenautsch S, Frencken JE, van't Hof M. Atraumatic Restorative Treatment Southampton, 1999.
And Dental Anxiety In Outpatients Attending Public Oral Health Clinics In South 40. Locock L, Chambers D, Surender R, Dopson S, Gabbay J. Evaluation Of The
Africa. J Public Health Dent 2007; 67: 179-84. Welsh Clinical Effectiveness Initiative National Demonstration Projects: Final Report.
20. Yamada MKM, Tanabe Y, Sano T, Noda T. Cooperation During Dental Southampton: Templeton College, University of Oxford and Wessex Institute for
Treatment; The Children's Fear Survey Schedule In Japanese Children. Int J Paediatr Health Research and Development, University of Southampton, 1999.
Dent 2002; 12: 404-9. 41. Morris A, Vito A, Bomba M, Bentley J. The Impact Of A Quality Assessment
21. Moore R, Brødsgaard I. Dentists' Perceived Stress And Its Relation To Program On The Practice Behaviour Of General Practitioners: A Follow Up Study. J
Perceptions About Anxious Patients. Community Dent Oral Epidemiol 2001; 29: Am Dent Assoc 1989; 119:705-9.
73-80. 42. Fitzgerald L, Ferlie E, Wood M, Hawkins C. Interlocking Interactions, The
22. Parashos P, Messer HH. The Diffusion Of Innovation In Dentistry: A Review Diffusion Of Innovations In Health Care. Human Relations 2002; 55:
Using Rotary Nickel-Titanium Technology As An Example. Oral Surg Oral Med Oral 14: 29-49.
Pathol Oral Radiol Endod 2006; 101: 395-401. 43. Altman DG, Bland JM. Statistic notes. Treatment Allocation In Controlled Trials:
23. Murphy EA. The Logic Of Medicine. Baltimore: Johns Hopkins University Press, Why Randomize? Br Med J 1999; 318: 1209.
1976. 44. Noseworthy JH, Ebers GC, Vandervoorst MK, Farquhar RF, Yetsir E, Roberts R.
24. Jüni P, Altman DG, Egger M. Assessing The Quality Of Controlled Clinical Trials. The Impact Of Blinding On The Result Of A Randomized, Placebo-Controlled
Br Med J 2001; 323: 42-6. Multiple Sclerosis Clinical Trial. Neurology 1994; 44: 16-20.
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

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22. PEDIATRIC DENTISTRY
Cleft Lips and Palates;
The Roles Of Specialists
DR. ABU-HUSSEIN MUHAMAD - DDS, MScD
Limited to Pediatric Dentistry
Athens-GREECE
Abu-hus@hotmail.com
left lips and cleft palates are among the most common Role of the Geneticist
C of birth defects and if left untreated can lead to serious
medical and concurrent speech and language problems.
However, while the consequences of cleft lips and
palates can be severe and long-lasting, these can be averted by
Consultation with a geneticist is crucial in order to do a DNA test
of the child with Apert's as well as the parents of the child. Per
the Mountain States Genetics Regional Collaborative Center's
website (accessed August 11, 2007) in Apert's syndrome, there
medical intervention, especially if it is done as early as possible. is bicoronal synostosis, midface retrusion, and symmetric syndactyly
This paper explores the various options for surgical, medical, (webbing of the digits) in both the hands and feet. The cranio-
dental, and speech and audiological management of cleft of the facial dysostosis syndromes are inheritable. Per Carinci et al (2005 ),
secondary palates in children with Apert's syndrome and the the gene mutation for each syndrome has been identified.
ways in which these interventions can help children with these Apert's syndrome is inherited in an autosomal dominant fashion,
particular birth defects. meaning that there is a 50% likelihood of recurrence of the syn-
We should begin this discussion by establishing what a cleft palate is, drome in the offspring of the affected individual. Often, the parents
Cleft Lips and Palates;The Roles Of Specialists
in medical terms. Per the Cleft Palate Foundation website (accessed of these children are not affected, and the gene mutation arises
August 17, 2007) a cleft palate occurs when the palatal plates spontaneously during development. However, the severity of
of an individual (which lie in the roof of the mouth) for various the syndrome may vary from one generation to the next. The
reasons fail to come together or “close” during the second month researchers state that the gene encoding for FGFR2 is mutated,
of fetal development. From an early age and up to adulthood, and this results in a wide spectrum in the expression of phenotype
the skull, face, jaws, hands and feet undergo frequent surgical and making anomalous development more complicated.
correction. These operations require planning and coordination Furthermore, Apert's may not have been detected in a parent,
amongst various specialists, including a neurosurgeon, a craniofacial until a child with more remarkable Apert's traits was born.
plastic surgeon, an anesthesiologist, a maxillofacial oral surgeon, Therefore DNA testing is of the utmost importance to give par-
an orthodontist, a dentist, an orthopedist and an orthopedic surgeon. ents the data to make informed decisions about the odds of
Continuing care throughout the first twelve years of a child with bearing another child with Apert's or other genetically inherited
Apert's life (as well as past the first twelve years) is facilitated by disorders. Lastly, it is of great importance to determine the co-
a social worker, psychologist, audiologist and speech language occurrence of other congenital and genetic anomalies that may
20
pathologist. In addition to the planning and performance of affect the progression of the child's development.
many operations at specialist clinics, each child and his or her
family should have regular contact with the craniofacial team. Role of the Speech Language Pathologist
There will often be meetings with several members of the mul- Therapy and follow-up care is coordinated with the speech language
tidisciplinary craniofacial team as well as other medical profession- pathologist (SLP). Per Shipster et al (2002), a cohort of ten children
als: the occupational therapist, the pediatrician, the nutritionist, with Apert's syndrome was studied and a thorough analysis of
the guidance counselor, the psychologist and the physiothera- their speech and language characteristics was done. They often
pist. For the purposes of this research paper there will be a have hyponasal resonance due to an under-developed midface,
focused discussion of six medical professionals' roles on the small nose, and excessively long soft palate. If there is a cleft
craniofacial team in the first twelve years of a child with Apert's palate, they may also have hypernasal resonance. Articulation of
life. These professionals are: geneticist, speech language pathol- speech sounds is often distorted due to the malocclusion and high
ogist, audiologist, plastic surgeon, dentist and orthodontist. arched palate. Impaired hearing or a general developmental
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

24. PEDIATRIC DENTISTRY
delay will also affect speech and language development. Otoloaryngologist) are: low-set ears, microtia, macrotia, posteriorly
Individuals with Apert's Syndrome often require glasses to correct rotated external ears, ossicular fixation, wide cochlear aqueduct,
near- or long-sightedness and thus the Speech Language Pathologist and abnormal surface configuration of the pinna. Regular audi-
must bear this in mind when doing drills using written media. ological testing is done according to schedule in order to assess
The researchers state that there are specific areas requiring therapy ongoing changes in the child's hearing.
based on their examination and standardized testing of these
children. Resonance and voice are at issue due to marked nasal Role of the Plastic Surgeon
obstruction, affecting the nasality of words produced by the chil- Per the Children's Craniofacial Association website (accessed
dren. Diplophonia and wet voice quality were apparent in the August 19, 2007) the physical characteristics of Apert's include
cohort's voice and resonance. As a result therapy must focus on defects of the skull, eyes, and face. The skull is: short from back
nasality and voice therapy as well. Testing of the cohort deter- to front, wide on the sides. The eyes are: bulging, eyelids tilt
mined severely impaired receptive and expressive language skills downward abnormally at the sides. The face is: mid-face has a
in nearly 50% of the group. This involves an approach to ther- sunken-in appearance, the upper jaw slopes backward, lower
apy which must address these issues to strengthen receptive and teeth project in front of the upper teeth. Early surgery relieves
consequently receptive abilities. Attention was delayed by 2;0 to the pressure on the brain and eyes by allowing the bone plates
3;0 chronological years. The cohort displayed single channel of the skull to be detached from one another. Even in severe
attention control that lags behind normal children. This means cases of Apert's syndrome a significant cosmetic and functional
that therapy must focus on eye contact, pragmatics and posture improvement is possible and a decreased risk of optic difficulties
issues. There were delays in the phonetic and phonological skills or blindness secondary to orbital hypoplasia can be achieved.
of these children. Phonetic errors mainly involved blade production Per Paravatty et al (1999) plastic surgery procedures include
of alveolar consonants as well as some lateralization of alveolar release of the prematurely fused sutures; the traditional surgery
fricative and affricates. While these issues mostly would be involves advancing the frontal bones, correcting the bulging eyes
helped by alveolar ridge surgery, in the meantime therapy may and upper facial deformities including the retrusion or hypoplasia
focus on proper articulation of these phonemes. Phonologically of the midface. Depending on the severity of Apert's syndrome
problems involved stopping of fricatives and affricates, final con- and the associated congenital abnormalities, other operations
sonant deletion, voicing of voiceless consonants, and fronting of such as rhinoplasty - plastic surgery of the nose, genioplasty -
velars and palatoalveolar sounds. These are all major areas for plastic surgery of the chin, eye muscle surgery to correct strabis-
Cleft Lips and Palates;The Roles Of Specialists
work on the part of the SLP. It is important to note that areas of mus or eyelid surgery to correct the abnormal downward tilt,
therapy for the cohort members during earlier years of life were: and surgical separation of the fingers and/or toes are performed
Portage and Makaton signing (which was relinquished to instead according to a staged treatment plan. To give the brain space to
work on spoken language). grow and to improve the shape of the head, the fused bones are
subjected to early surgery, often when the child is six months old.
Role of the Audiologist Corrections of the midface and jaws are currently not undertaken
Per Rajenderkumar, Bamiou and Simimanna (2005), the major until adolescence, when all the permanent teeth are in place. It
concern related to audiological treatment of Apert's is the risk of is also important to note that plastic surgery of the hand in
hearing impairment caused by repeated infections in the middle Apert's syndrome often has to be started early, to allow the child
ear. However, the researchers point to the significant debate to develop a grip.
regarding the efficacy of repeated pressure equalization tube Per the Mountain States Genetics Regional Collaborative
insertion vs. the efficacy of amplification to ensure hearing ability. Center's website (accessed August 11, 2007), the fingers are all
Otoloaryngologists will handle the middle ear infections by separated and shaped, using skin and possibly also bone transplants.
22
inserting pressure equalization tubes into the eardrum to equalize This may enable the child to have three to five fingers on each
middle-ear air pressure and drain liquid. The audiologist will hand. After such surgery, the child will require training under the
check the ears for placement of the tubes as they often fall out supervision of an occupational therapist to develop grip and
of place. coordination; the Speech Language Pathologist will work on
Per the researchers, some individuals may require hearing aids, as a similar issues of tone and articulation related to muscle strength
hearing impairment will affect speech and language development. in the speech mechanism.
They argue based on their data from a cohort of seventy cases Per Sadove, Van Aalst, and Culp (2004) the plastic surgeon is
that hearing aids are more effective than tube insertion in the involved in early repair of the cleft lip in the first few months of
long run. Hearing impairments caused by sensorineural damage life and works with the dentist and orthodontist to manage
(the inability of the nervous system to mediate sound impulses) appliances to close the cleft in the secondary palate. The surgeon
are uncommon. Further impairments of hearing that are monitored also is involved with surgery to the hands and feet to create digits.
and managed by the audiologist (with consultation with a Regarding the secondary palate surgery, there are a number of
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

26. PEDIATRIC DENTISTRY
approaches. These include the von Langenbeck repair, the Veau- school age. The purpose of this device is to bring the maxilla in
Wardill-Kilner palatoplasty, two-flap palatoplasty, vomer flap surgery, alignment with the rest of the head, with consideration of the
Z-furlow (Z-plasty), and four-flap palatoplasty surgeries. It is mandible and dentition in the process of the orthopedic treatment.
important to note that the researchers report the discussion There is debate as to the proper timing for orthopedics and the
between two schools of thought on repair timing. One is to efficacy of using extra-oral pin-retained appliances versus passive
repair early in life to accommodate the onset of speech at 1 year appliances. Per the researchers 54% of craniofacial centers use
of age, vs. delaying repairs to allow for maxillo-facial growth neonatal maxillary orthopedics.
with a complete transverse facial growth at 5 years of age. The The second process involves orthodontic treatment of the decid-
current approach stated by the researchers, is to do the soft uous dentition stage, which the researchers state has a direct
palate repair at 0;3 to 0;6 and the secondary hard palate by 1;6 CA. correlation with the patency of circummaxillary sutures. This
occurs in the latter period of 5;0 to 7;0 years. It is significant to
Role of the Dentist reiterate the research of Kaloust, Ishii, and Vargervik (1997),
Dental treatment is necessary in the case of Apert's syndrome. bearing in mind once again that there is a 0.96 year delay in
Per Kaloust, Ishii, and Vargervik (1997) the oral cavity of these dentition of Apert's vs. normal children's dentition. Treatments
children is characterized by supernumary teeth, missing teeth, are needed for the lack of deciduous dentition in the area of the
impaction and crowding, and delayed eruption. The maxilla is alveolar cleft, and these treatments may include a face mask to
affected and the mandible has an abnormal shape and size. protract growth. Treatment to manage crossbite includes equili-
The dentist works closely with the orthodontist to time adjustments bration for occlusal interference.
to the oral cavity and dentition. The researchers point to two sig- The third process is in the mixed dentition period in the 9;0 to
nificant findings: a delay of 0.96 years vs. a normal timeline of 11;0 years age range. This is concurrent with alveolar bone
dentition, as well as a marked slowdown in dental maturity that grafting, 6 months prior to graft insertion with fixed appliances
slows more notably with age. This means that the dentist must placed on the maxillary arch. The researchers explain that this
time their involvement with the patient along these parameters. eliminates crossbite and other unfavorable consequences of mal-
They will work on extraction of supernumary teeth and impaction positioned incisors, and helps with dental aesthetics.
and crowding, but the work is done at different ages as normal Eruption of the canine adjacent to the cleft of the secondary
children. The dentist also works closely with the orthodontist palate is of importance as this will control the timing for further
and plastic surgeon to assess dentition all the while that process- orthodontic treatment. The researchers point to evidence that
Cleft Lips and Palates;The Roles Of Specialists
es are worked on for closing the alveolar ridge after age 5;0 as the canines erupt in synchronicity with bone graft placement.
well as palatal closure and velopharngeal port surgeries. The fourth process is in the permanent dentition stage, anywhere
Per Shipster et al (2002), there are a remarkable number of from 10;0 to 13;0 years of age or even older. In this period there
cases that present with Class III malocclusion, specifically Class III is a determination whether orthognathic surgery is indicated.
incisor relationship, anterior bite and bilateral posterior crossbite. The researchers state that there is a high percentage of patients
The degree of incisor crowding and irregularity is variable among that require this surgery vs. the general population, but that it is
cases. The dentist considers how difficult it is for the child to not needed in more than 10% of the Apert's and cleft palate
maintain good oral hygiene owing both to crowded teeth and to patients. This is particularly relavent in Apert's patients as they
restrictions in fine motor skills. An electric toothbrush may be a have a high incidence of Class III skeletal issues and thus the
useful aid. Frequent appointments with the dentist and/or a den- orthodontist carefully exams the other evidence from the cranio-
tal hygienist are important and, as there is an increased risk of facial team in order to determine candidacy for treatment.
caries, preventive fluoride treatment should be given.
Conclusion
24
Role of the Orthodontist There is clearly a need for further and more controlled research
Orthodontists play a significant role in the treatment of a child on the disciplines involved in the craniofacial teams. There is a
with Apert's syndrome. Per Kuijpers-Jagtman (2006) there are need for larger cohorts to gather more data specific to Apert's
four distinct processes that the orthodontist will participate in up syndrome as this will give better evidence about treatment efficacy
to and beyond the child's twelfth year of life. The orthodontist and treatment outcomes. The craniofacial teams should be
will confer with the dentist and plastic surgeon that care for a advised to produce studies that have to do strictly with Apert's
child with Apert's. This is to determine proper timing for the syndrome so that the body of research regarding genetics in par-
implementation of orthodontic treatment. ticular so that models for future treatment can be perfected even
The first process begins from 0;0 to 7;0 years, after the initial more for the benefit of these patients.
treatment plan is devised with the craniofacial team. This is the
period during which the orthodontist constructs neonatal maxil-
lary orthopedics for the child ages infant through elementary
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009

28. PEDIATRIC DENTISTRY
REFERENCES
Cleft Palate Foundation (2007). About Cleft Lip and Palate. Retrieved August 13, from a Genetics Consultation. Retrieved August 11, 2007, from
2007, from http://www.cleftline.org/parents/about_cleft_lip_and_palate. http://www.mostgene.org/dir/expect.htm.
Carinci, F., Pezzetti, F., Locci, P., Becchetti, E., Carls, F., Avantaggiato, A., Becchetti, Paravatty, R., Ahsan, A., Sebastian, B., Pai, K., Dayal, P. (1999). Apert syndrome: A
A., Carinci, P., Baroni, T., & Bodo, M. (2005). Apert and Crouzon's Syndromes: case report with discussion of craniofacial features. Quintessence International,
Clinical Findings, Genes and Extracellular Matrix. The Journal of Craniofacial 30(6), p. 423-426.
Surgery, 16(3), p. 361-368. Rajenderkumar, D., Bamiou, D., & Sirimanna, T. (2005). Management of hearing
Children's Craniofacial Association (2007). A guide to understanding Apert's Syndrome. loss in Apert syndrome. The Journal of Laryngology and Otology, 119, p. 385-390.
Retrieved August 19, 2007, from http://www.ccakids.com/Syndrome/Apert.PDF. Sadove, A., Van Aalst, J., & Culp, J. (2004). Cleft palate repair: art and issues.
Kaloust, S., Ishii, K., & Vargervik, K. (1997). Dental development in Apert Clinics in Plastic Surgery, 31, p. 231-241.
Syndrome. Cleft Palate-Craniofacial Journal, 34(2), p. 117-121. Shipster, C., Hearst, D., Dockrell, J., Kilby, E., & Hayward, R. (2002) Speech and language
Kuijpers-Jagtman, A. (2006) The orthodontist, an essential partner in CLP treatment. skills and cognitive functioning in children with Apert syndrome: a pilot study.
B-ENT, 2(4), p. 57-62. International Journal of Language and Communication Disorders. 37(3), p. 325-343.
Mountain States Genetics Regional Collaborative Center (2007). What to Expect
Cleft Lips and Palates;The Roles Of Specialists
26
DENTAL NEWS, VOLUME XVI, NUMBER III, 2009