Lupine Publishers | Board Certification in Pediatric Dentistry: Once it Represented the Pursuit of Excellence

Lupine Publishers | Journal of Pediatric Dentistry

Abstract

The scope and changes to the examination format for Board Certification by the American Board of Pediatric Dentistry has successfully achieved the goal of enticing and attracting significantly greater numbers of AAPD members to pursue and complete the board process. Unlike earlier times (prior to 2002), when only 15% of its membership secured Diplomate status, changes in the examination format that reduced the process from four extensive and demanding components to two much abbreviated elements, approximately 80% of its membership has now pursued and achieved certification. For better or worse, standards have been radically modified from that of elite and prestigious to that of minimally acceptable. Movement in the direction of making the examination process more attractive and simplified has become the rule rather than the exception. The bar has been sufficiently lowered by the nature of the examination changes. In so doing the demand and requirements for pursuit of knowledge has diminished. A priority for expanded membership at a significant cost has overshadowed the pursuit of excellence among the masses. The old school of thought envisioned inherent motivations to continually seek excellence and the most comprehensive level of knowledge. Its opposing school determined that inclusion of those unwilling or unable to master the highest level of competency remained deserving of recognition. Among the dilemma created by this shift in priorities is that once one fractionates the degree of difficulty and challenge to a lesser level, it is unlikely the direction can be reversed any time soon.

Introduction

What it once meant to achieve Diplomate status from the American Board of Pediatric Dentistry appears no longer to be what it once represented. In the early 1980’s approximately 15% of the membership of the American Academy of Pediatric Dentistry sought and achieved this prestigious credential. Those achieving this lofty accolade were generally recognized as among the best and brightest in the field. Aspirations to secure Diplomate status were essentially limited to those with the broadest range of knowledge and commitment to excellence and lifelong learning. For whatever reasons, it became apparent that the rigorous nature of the existing four part format remained a deterrent for many to pursue Diplomate status. It became clear that examination format changes represented the only course of action for the board to increase its membership. During the following decade or so, changes in the perception of what this credential represented underwent an evolutionary change foreign to what purists think of today as a movement in an upward direction. The compass appears to have deviated in the direction of lowering rather thana raising of standards, let alone the pursuit of excellence. This was not limited to pediatric dentistry; rather instead, most medical and dental disciplines acknowledged that there was a greater need to secure and encourage larger numbers of their constituents to demonstrate this credential. In so doing, practicality and economics dictated that the ultimate attraction to accomplish this objective was that certification examinations must be abbreviated, and the bar lowered as needed to include rather than limit greater numbers from achieving certification.

Amidst the rationale for change included the fact that hospital bylaws in the late 1980’s began adopting the position that if a specialty had an American Board, that its members would need to demonstrate certification at the time of re-appointment. Significance for pediatric dentists was their ability to make use of hospital operating rooms for general anesthesia. For those unwilling to pursue board certification, the use of itinerant anesthesiologists and free-standing surgical centers was and has become an alternative, without consequences of not having achieved board certification. Nevertheless, until the format of the examination was reduced, from a rigorous four part process to a significantly abbreviated two part format, the gross numbers electing to pursue certification was not increased. To demonstrate that a significant portion of its members pursued Diplomate status, the ABPD was compelled to re-examine its criteria for certification. Perceptions of its existing degree of difficulty, time commitment, and ultimate outcome gave rise to recognition that without a substantial revision in format, increase in those pursuing certifications was unlikely. Revisions of the four part examination to an abbreviated two part exam became inevitable in not only pediatric dentistry but included orthodontics and other specialty areas. In doing so, a complete renovation in thinking took hold in that redefinition of standards was needed to permit increasing numbers to qualify as diplomates within their field. The pursuit of excellence gave way to what constituted for some, mediocrity or minimally adequate. Frank recognition that requirements for current day certification markedly differ from those of before goes largely unacknowledged. Historically, the original format comprised an all-day written examination, generated from a defined list of 200 carefully selected and identified classical as well as contemporary articles spanning all areas of pediatric dentistry. Each multiple choice question was referenced to a specific article. Successful completion of this preliminary component granted eligibility to participate in Section 2 (a no holds barred one hour oral examination before two examiners). Section 3 consisted of the submission of 5–6 specific types of cases treated which included detailed and meticulous write-ups, pre- and post-treatment radiographic evaluation, with follow-up care to demonstrate diagnostic, technical skill and clinician judgment. Upon successful completion, applicants qualified for part 4 an all-day clinical site visit in which any aspect of clinical care and practice was evaluated by two examiners, in one’s clinical or academic setting.

Effective in 2001, the four section format was reduced to two sections. Part one consisted of a half-day multiple choice written examination, based on an unidentified list of texts and papers from the literature. Satisfactory completion permitted candidates to pursue section 2 which served as a 1 1/2 hr clinical simulation on a small range, in essence replacing sections 2,3 and 4. During this period, for one year, till 2002, candidates had the option of choosing between the four part format and the abbreviated two part formats. In recognition that the new format constituted an abbreviated revision, concerns emerged with respect to a potential need for development of a Re-Certification component within a ten year span. Over the next decade, consistent with the concept of Re-Certification developed by the ABPD and other disciplines, a protocol with intent to demonstrate a propensity for Diplomates to continue to manifest a course of lifelong learning resulted in the formulation of a 50 question, open-book multiple choice recertification examination mandatory for those having passed the two part format (granted limited Diplomate status every ten years). 80% correct responses were needed to pass. Unlimited Diplomates (those having completed the more rigorous four part format) today remain exempt or voluntarily excused from recertification unless they chose to participate in any capacity related to examination development or appointment to the board.

Differences in Qualification for those having completed the more comprehensive examination format

At present, there is no distinction amongst which format was undertaken and Diplomate status rewarded other than the subtlety of limited vs unlimited status and a requirement for Re-Certification for those with limited status. Questions remain whether the fifty question open book multiple choice re-certification exam constitutes a valid comparison between examination formats. An argument might be made that individuals who subjected themselves to the four part format possess a sufficient commitment to lifelong learning and keep abreast of new and changing literature. If this premise is accepted, would it not be appropriate to provide distinction in Diplomate status in some recognizable way. The AAPD has reviewed and re-assessed the granting of Fellowship status in the last few years and as such, might consider re-assigning qualification acknowledgment of differential levels of Diplomate status.

For those having completed the four part format, the pursuit of excellence applies; from the perspective of the shortened format, adequacy is implied. The two accolades are distinctly different from one another, granting equal recognition however, seems rather inappropriate. In the course of the past decade, this author has interviewed numerous board certified candidates in search of both academic and private practice positions. Query of knowledge and competency across many fundamental areas of pediatric dentistry including pediatric medicine, recognition and management of medical emergencies, simplified as well as sophisticated sedation techniques, thorough understanding of transitional dentition analysis, cephalometric and orthodontic diagnosis and mechanics, and clinical experience can often at best be described as weak. It should not be surprising that a significantly abbreviated certification process does not possess the latitude to include some or all of these areas in detail. Helpful to analysis of the merit of the different schools of thought along with respective format changes, the ABPD might seek to secure a survey of its the membership who have experienced both sides of the examination format. Similarly, it may wish to explore perceptions of the value and validation of the current Re-Certification requirement that impacts on candidates who have completed the contemporary reduced examination format. A survey to accomplish such is currently underway by this author.

Summary

The decision of the American Board to reduce the directive from the pursuit of excellence to one of lessor proficiency and competency has been both diligently conceived and scrutinized. Keeping pace with other disciplines who similarly saw need to increase their certification membership, the ABPD made the decision that Board Certification should not have as its mission. the quest for excellence, that a hint in its direction is enough to inspire its membership. In all fairness, this change was made and influenced by both internal and external pressures. Among external influences was societal pressure to increase the numbers of health care providers who were acknowledged to possess a certain degree of competency through their respective disciplines. Low numbers of board certified members within a given field implied that the majority fell seriously short of what the public should expect. Increased demand for competency as mandated by certification served as a logical outcome for medical societies to re-examine their criteria and expectations for certification. The notion of distinction and elite knowledge while once selected as optimal, has been replaced by an expectation of what constituted a minimally acceptable level of competency achievable by most of its providers. These distinctions comprise a dynamic process the ABPD is strongly committed toward improvement. While critical analysis is in general both easy and prevalent, the task for which the ABPD undertakes is by no means an easy one.

Disclaimer

The opinions expressed in this editorial are those of the author and in no way be construed to represent or reflect the views of the ABPD or AAPD.

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Management of Internal Root Resorption with Bioceramic Material on Permanent Tooth-A Case Report | Lupine Publishers

Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Internal root resorption (IRR) is a category of pulp disease characterized by the loss of dentine as a result of the action of clastic cells stimulated by pulpal inflammation. The objective of this case report was to account for the diagnosis and management of an internal root resorption without perforation. The patient, a 26-year-old male, came to Guru Nanak Institute of Dental Sciences and Research, West Bengal, without having symptoms in the tooth. Endodontic treatment was performed using the following methods: irrigation of the root canal with 2.5% of sodium hypochlorite, then calcium hydroxide (CH) was applied as intracanal medicament for one month. Complete instrumentation was done with Hyflex One File (Coltene) and obturation with corresponding guta-percha and Roeko Guttaflow Bio seal sealer (Coltene). The patient was checked after one week and then after six months. He did not have any symptoms and IOPA radiograph did not show any further progression of the lesion.

Introduction

The Glossary of the American Association of Endodontists defines internal root resorption (IRR) as a condition associated with a physiological or pathological process that results in the loss of dentin, cement and bone [1]. Most teeth with internal root resorption are symptom free and are first clinically recognized through routine radiographs. However, when resorption actively progresses, the tooth is only partially vital and may present typical symptoms of pulpitis. Bell (1830) first reported about IRR. Mummery (1920) called it “pink tooth of Mummery” due to the presence of pink discoloration on the crown [2]. This condition, although rare, is more frequent in the male population. The IRR is more common in the presence of a periapical lesion. Its prevalence was estimated between 0.01% and 1% depending on the inflammatory condition of the pulp [3]. The IRR could be caused by several stimuli: trauma, chronic inflammation of pulp/periodontal ligament, heat created by the friction of drills during the preparation of cavities, cracked tooth syndrome, tooth reimplantation and orthodontic treatment [4]. There have also been reported cases of internal reabsorption caused by Herpes Zoster virus [5]. The IRR is caused by inflammatory stimuli which produce an alteration of the odontoclast inhibitory mechanism resulting in an alteration of the pre-dentine layer. The vascular change in the pulp produces hyperemia increasing oxygen tension and causing an acidic pH level that attracts multinucleated cells, odontoclasts and dentin clasts. Dominance of inhibitory substances such as OPG (osteoprotegerin) as activators of RANKL (receptor activator of factor kappa B ligand) followed by swelling, results in the rupture of protective coatings allowing the invasion of odontoclasts and initiating resorptive patterns. Connective, post-resorptive activity tissue transforms into metaplastic granulation tissue [6]. Generally, IRR detection is done by X-rays, however, the use of cone beams computed tomography (CBCT) has been reported to be highly useful for diagnosis in endodontics, since it shows the lesion in detail and includes information about adjacent anatomy, which X-rays does not provide [7]. The periapical radiography is limited because it provides a twodimensional image [8], whereas diagnosis by CBCT shows images in all their dimensions through tomographic slices, without image overlay [9]. Also, diagnosis by CBCT may improve the accuracy and efficiency in the prognosis of the tooth [10]. Therapeutically, the biomaterial employed can influence the prognosis of the nonsurgical endodontic treatment done for extensive internal root resorption [11]. MTA is most commonly used in these cases because of its sealing ability, biocompatibility and potential induction of osteogenesis and cement genesis and it can be used in a humid environment [12]. Another study using an experimental immature tooth model, demonstrated that the MTA also increased the fracture resistance of bovine incisors when submitted to different reinforcement treatments Recently bioceramics are widely used in endodontics. Roeko Guttaflow Bio seal (COLTENE) is a bioceramic endodontic sealer which claims to avoid shrinkage upon setting as it has Zirconium oxide is used as the radiopacifier, and the material is claimed to be aluminum-free, non-soluble and does not shrink during setting. It gives advantage of flow of material as well as sealing ability which better bond with the corresponding gutta percha used for obturation [13]. The purpose of this case report is to describe the diagnosis and clinical management of an internal root resorption with bioceramic material.

Case Report

Male patient, 26 years old, treated at the post graduate department in Guru Nanak Institute of Dental Sciences and Research. The patient reported no pain at the time of appointment the chief complaint was discoloration of the front tooth which was traumatized 5 year back. Vitality tests using Endo-Ice (Coltene, Switzerland) were performed in [11]; the tooth gave negative response. The patient did not present tooth mobility and periodontal pockets. IOPA radiograph of the affected tooth#11 showed an oval enlargement (ballooning out) of the root canal space (Figure 1). The pulp chamber and canal cannot be followed throughout the lesion. Radiograph performed at different angulation to confirm the resorptive lacunae is a continuation of the distorted border of the root canal. Endodontic treatment was suggested; therefore, isolation protocol was performed to make the cavity opening later (Figure 2). Working length of the tooth was determined by IOPA radiograph using #15K file (Figure 3) and the result was confirmed with apex locator Canal Pro (COLTENE). After removing the pulp tissue properly chemical-mechanical instrumentation was performed with Hyflex One File (COLTENE) and irrigation was done with 1ml of 2.5% of sodium hypochlorite between each time instrumentation with 30-gauge side vented needle. This was followed by irrigation with normal saline to remove any remnants of hypochlorite, later canal was dried with absorbent points. Ca (OH)2 dressing was given for 1month and the medicament was changed weekly. After one month, temporary restoration was removed with [4] round diamond bur, canal was irrigated with 5 mL of 2.5% sodium hypochlorite (NaOCl) and 5 mL of 17% of ethylenediaminetetraacetic acid for removing the Ca (OH) dressing and then the canal was flushed with normal saline and dried.

Figure 1: .

Figure 2:

Figure 3:

Figure 4:

Figure 5: .

After removing the medication, obturation was done with Hyflex corresponding Gutta Percha and the remaining pulp chamber was obturated with Guttaflow Bio seal sealer (Figure 4). Access cavity restoration was done with light cure composite resin. The patient was recalled after 6 and 12 months (Figure 5, 6) for clinical and radiographic follow up. Clinical examination of tooth was functional without sensitivity to percussion or palpation [11].

Figure 6: .

Discussion

There is always a dilemma of whether to treat a tooth with a questionable prognosis endodontically or extract it and subsequently place an implant. Bell first reported a case on internal resorption in 1830. Since then there have been numerous reports in the literature [14]. Two types of internal root resorption are generally described: the internal root canal inflammatory resorption and the internal root canal replacement resorption. In the inflammatory resorption, the resorptive process of the intraradicular dentin progresses without adjunctive deposition of hard tissues adjacent to the resorptive sites. The phenomenon is associated with the presence of granulation tissues in the resorbed area and identifiable with routine radiographs as are radiolucent zone centered on the root canal. In the replacement resorption, the resorptive activity cause defects in the dentin adjacent to the root canal, with concomitant deposition of bone like tissue in some regions of the defect. It results in an irregular enlargement of the pulp space with partially or fully obliterated area of the pulp chamber. Internal resorption is the result of an inflamed pulp and the clastic precursor cells recruiting through the blood vessels. Treatment of internal resorption is quite predictable as it is easy to control the process of internal root resorption via severing the blood supply to the resorbing tissues with conventional root canal therapy. Intraoral X-ray of IRR is characterized by the radiographic appearance of an oval shape enlargement within the pulp chamber or the root canal. However, the early diagnosis of the IRR is difficult by examination of a conventional X-ray. If IRR is suspected, several shots under different angles of incidence are recommended. In the treatment of internal resorption, the use of calcium hydroxide also has two other important goals: to control bleeding, and to necrotize residual pulp tissue and to make the necrotic tissue more soluble to sodium hypochlorite. Because of the limited access by instruments to all areas of the resorption cavity, chemical means are needed to completely clean the canal. Studies on the effectiveness of sodium hypochlorite and calcium hydroxide to remove the resorptive and other tissues from the root canal indicate that they have an additive or even synergistic effect [15]. In cases where the resorption has not perforated, it is usually enough to use calcium hydroxide paste in the canal once from 1 to 2 weeks. This allows removal of the residual tissue at the next appointment by irrigation and instrumentation. In our treatment protocol, we choose Guttaflow Bio seal (COLTENE) sealer due to its versatile property of Bioceramic component & gutta-percha particles. Upon contact with fluids, this material provides natural repair constituents, such as silicates and calcium, which contribute to the activation of biochemical processes, providing additional support to the root canal regeneration. A novel material for root canal filling that combines gutta-percha in a powder form with a particle size of less than 30 μm and a sealer. The sealer has also showed least cytotoxicity as well as inflammatory reaction [15].

Conclusion

It is puzzling in diagnosing and treating a root resorption case, therefore a suitable management is perilous. Thorough investigations and discussion are required for the management especially when the prognosis of the tooth is poor upon consultation. Absence of periapical lesion and no signs and symptoms at the 12-months review provided a favorable outcome to once a tooth of hopeless prognosis.

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Lupine Publishers - Journal of Pediatric Dentistry

Management of Mesiodens In Mixed Dentition- Molariform and Tuberculate: A Case Report by Reena Augustine in Interventions in Pediatric Dentistry Open Access Journal - Lupinepublishers

Timely intervention is the key to any setback in the mixed dentition. Teeth which are supplemental to the normal dentition are supernumeraries, the most common being mesiodens, present in the premaxillary region. Certain pathological consequences may arise due to mesiodens like unaesthetic midline diastema, rotation, displacement, root resorption and cyst formation. The current case report presents the management of developing malocclusion in the anterior region due to the presence of mesiodentes- a molariform and a tuberculate. The molariform mesiodens was impeding the eruption of the maxillary right central incisor, thus the surgical removal of both mesiodentes was planned and executed. In addition to this soft tissue uncovering was done for the unerupted maxillary central incisor. On follow up, uneventful healing was observed successfully. Supernumerary teeth, or hyperdontia, is a term that describes teeth that are surplus in number when compared to the normal complement of teeth [1]. The etiology of supernumerary teeth remains unclear and not yet completely understood [2]. Among the various proposed theories that have attempted to explain the causes behind the development of supernumerary teeth, current literature favors the ‘lamina hyperactivity theory’ that states hyperdontia results from independent, locally conditioned hyperactivity of the dental lamina [1]. The most commonly occurring supernumerary tooth is the ‘mesiodens’, a term that was initially coined by Balk in 1917.As the name suggests, the mesiodens is usually located mesial to the central incisors in the premaxillary region [3].

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