Lupine Publishers | Maryland Bridge : A Treatment Option in Children

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

The most common traumatic injury encountered in a pediatric dental set up is avulsion. Loss of permanent anterior teeth at a young age can have an impact on the psychological development of the child. Reimplantation if not possible, the anterior tooth can be restored with either removable or fixed prosthesis depending on the completion of the growth. To overcome the limitations of removable prosthesis, temporary fixed prosthesis can be an option in restoring the esthetics and functions when growth is not completed. Maryland bridge is an ideal option as a fixed temporary prosthesis in such patients.

Keywords: Avulsion; maryland bridge; re-implantation

Introduction

Over the last few decades dentistry has taken its turn towards more conservative and preventive treatment modalities. This has been possible not only because of the improved and advanced materials and techniques but also because of the understanding to preserve the natural tooth as far as possible. Reasons for tooth loss could be congenital absence, caries or trauma. Of these, traumatic injuries resulting in avulsion of the tooth is one of the common causes for tooth loss in the anterior region of the oral cavity. Trauma to the anterior teeth is common in childhood, one study reported that out of 2,100 children (aged 8-14 years) surveyed for teeth fractured due to trauma, 60.74% were aged between 11 and 14 with 13.8% cases involved incisors [1]. This case report presents a case of replacement of missing anterior teeth because of avulsion with direct fiber reinforced resin composite.

Case Report

A 13-year-old boy reported to the Department of Pedodontics and Preventive dentistry with a chief complaint of avulsed tooth in the maxillary front region of the jaw for three weeks. Patient had a fall while riding bicycle. The patient was healthy without any significant medical and dental history. On extra-oral examination no abnormalities were found. On intra-oral examination soft tissues were normal avulsed socket was all healed. Patient had no bruises or scars on his body after the fall. Maxillary right lateral incisor had avulsed was seen with respect to maxillary right lateral incisor (Figures 1&2). Patient had reported to our department after three weeks with his natural avulsed tooth . The avulsed tooth was not stored in any media by the patient and was not in a good condition to be used as pontic as it had become dehydrated and had lost its color from the normal one. As the patient growth was not completed implant was not an option. Patient was very concerned about his esthetics and wanted immediate replacement. An option of conservative and conventional fiber reinforced composite resin bonded pontic was selected for the prosthetic rehabilitation. A composite buildup of maxillary right lateral incisor was done on a diagnostic cast. On the diagnostic cast the length of the FRC fiber (everstick, GC company) was pre-measured from the half the maxillary right canine to the half of the maxillary right central incisor. The fiber was pre-measured in such a way that it followed the contour of the ridge.

Figure 1: Intraoral view showing missing maxillary right lateral incisor.

Figure 2: Radiographic view.

Figure 3 Ever stick fiber placed on palatal Grooves.

Figure 4: Composite build-up pontic.

The palatal surface of the maxillary right canine and the right central incisor was roughened for better adaptability of the fiber for good retention. The surfaces were roughened using coarse flame shaped bur. Then the roughened surfaces of the abutment teeth was etched and bonded and then the fiber was placed starting from the canine to the central incisor and it was well adapted on the surface with a plastic carrying instrument. Then the fiber was bonded using composite in such a way that the fiber was at the center of the bonded tooth and was not in occlusion (Figure 3). Then a groove was made palatally on the composite build up pontic so that the fiber inserts well in the pontic for better retention (Figure 4). The pontic was bonded with composite keeping the arch form and function in harmony (Figures 5&6). The roughened surfaces were smoothened and polished with finishing and polishing kit (Enhance Composite Finishing and Polishing System Dentsply Caulk Dentsply International Inc, Milford, DE). The patient was followed for 6 months and had no complaints with the prosthesis.

Figure 5: Fiber reinforced bridge replacing missing tooth.

Figure 6: Occlusal view with replaced missing tooth.

Discussion

The patients with lost anterior teeth require immediate attention for the restoration of the aesthetics and function. The various treatment options available for restoring missing anterior tooth after avulsion are reimplantation, removable partial denture or fixed prosthesis depending on the case. In the present case the patient reported with the avulsed tooth after 3 weeks so reimplantation of the tooth was not a treatment option. Removable partial dentures are the most easily fabricated and cheapest options available, but they are often unacceptable to the patient because they are bulky, uncomfortable and not very esthetically pleasing [2]. Replacement of missing teeth with conventional fixed partial denture can involve tooth preparation of abutment teeth which can cause hypersensitivity, pulpal injury [3]. Fiber reinforced bridge was opted in this case, in order to provide a single visit, cost effective and a minimally invasive fixed solution to the patient. Clinical studies have shown a substantial clinical performance of the FRC FPDs, with an overall survival rate of 75% after about 5 years, which are higher than that of the FPDs with metal frameworks [4]. Hence high pulp horns of abutment teeth, expected transition in the position of the gingiva and age of the patient were factors that precluded the use of conventional fixed prostheses in this case. The resin material used in this study was GC Ever stick as a bridge for replacement of missing tooth. Accurate bonding between the fibers and composite is the key factor for a successful treatment. The resin fiber used has a unique, interpenetrating polymer network structure (IPN) which leads to superior bonding enabling reliable surface retained applications and perfect handling properties. The use of FRC bridges also allows utilization of a patient’s natural crown as a pontic if the tooth or tooth crown is still intact [5]. In our case the lost tooth was fractured and was not in good condition to be used as a pontic, so the composite build up tooth was used (Figure 4). A study was done involving 358 patients which concluded that the patient’s acceptance was better with resin bonded fixed partial dentures [6]. Maryland bridge is a minimal invasive procedure with less harm to the abutment tooth, minimum chair side time and less cost. It is well accepted by young patients and can be used as a treatment option for avulsion cases.

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Lupine Publishers | Assessment of Dental Neglect and It’s Relation to Oral Health Among School Children Aged 4-12 Years in Sri Ganganagar City, Rajasthan, India

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Background: Dental neglect indicates that parents or guardians fail to give the necessary oral health requirements such that the child can take pleasure in function and free from disease, where reasonable means are accessible to parents or caretaker.

Aim: The aim of the study was to evaluate the dental negligence of parents towards their children aged 4-12 years in Sri Ganganagar city, Rajasthan and to correlate the oral health status of the children.

Materials and Methods: A cross‑sectional study was done involving 1000 school going children and their parents. Questionnaire were distributed among the parents of the children which includes the details of parents and their children . WHO form was used to assess the oral health status of the children i.e. the dental caries and bleeding on probing as per the World Health Organization criteria,2013 index. Statistical analysis was done by using SPSS software version 20.0.

Results: A significant higher dental negligence score was found among those parents who resided in the suburban area and whose educational qualification was higher secondary only and those who had visited the dentist only after the development of symptoms in their children.

Conclusion: Among the parents whose educational qualification was higher secondary only, those who resided in the suburban area and those who went to see dentist only after the development of symptoms in their children have shown poor health status.

Keywords: Dental neglect; dental caries; oral hygiene; parents

Introduction

Dental neglect indicates that how known knowledge of oral health care are not fulfilled which fails to do the proper maintenance of oral cavity. For proper oral health care people need to be aware of the dental problem consequences. In spite of giving so much dental professionals and audio-visual dental care measures, only a small number of people take proper dental home care and they do not go for periodic dental checkup. Oral health is considered as the central importance for our general health and well-being. A healthy oral cavity allows an individual to communicate, have food and participate in social activities without having any disease, discomfort or difficulty. Having oral disease can be expensive in terms of money and also life style can be changed [1]. The World Health Organization has stated that neglect should be differentiated from conditions like poverty, where it shows dental neglect is present only where there are available resources. It was found that there is a great deal of severity of dental neglect worldwide [2].

Materials and Methods

Ethical approval for the study were taken from the concerned authority of the institution. This ensured that participants involved in the study were randomly selected from the schools of Sri Ganganagar city. This study was conducted from January 2019 to August 2019. The age of the children were 4 to 12 years, and the questionnaire were given to the parents of the children to be answered. An informed consent was obtained from the parents earlier. The parents were asked to answer the questionnaire which had details of both parents and children. Consent form from parents were taken for the survey to be done. Oral examination of children was conducted by using disposable mouth mirror, straight probe and CPTIN probe in a natural day light. Oral status was recorded according to the WHO form, 2013. The collected data were tabulated and subjected to statistical analysis using SPSS software version 20.0, (SPSS Inc., Chicago Ill., USA) and levels of statistical significance were set at P < 0.05.

Results

Graphs 1&2: Shows the address and parental education level.

A total of 1000 pair of parents and children participated in the study, of which female and male parents were of 631 and 369, respectively. Table 1 illustrate the comparison of key background variables and dental service used in previous two years and Table 2 shows the p value for the oral status with respect to key background variables (Graphs 1&2). It is showed that with respect to dental neglect scores, a significant higher dental neglect score was reported among the people who resided in the suburban location, parents whose educational qualification was higher secondary only, parents whose visit to the dentist were only after the development of symptom, parents those who used only school dental services and those who used dental service only once in previous two years.

Table 1: Comparison of key background variables with respect to given demographic status.

Table 2: .

*P value is statistically significant, **P value is statistically highly significant.

Discussion

Oral health occupies a very significant role for the wellbeing of individuals, and parents’ behavior and way of thinking influence the oral health of their children [3]. Prevention is always better option than cure. People should be very thoughtful and particular to maintain oral health for the prevention of oral disease. Dental professionals and audio-visual media provide the essential dental care measures [4]. But the fact is that only few people take adequate regular home dental care and do not go for periodic/yearly dental check to the dentist to keep their oral cavity healthy [5]. It has been seen that dental neglect is mostly related to the illiteracy amongst low socio-economic class and the prevalence of oral diseases are highest amongst them [6]. Child neglect is a very important subject in terms of prevalence and severity–it is the most common cause for a child to be made subject to a child protection plan in the UK - and there is indubitable evidence and facts that it is harmful and damaging to children [7-10]. There is very scarce literature regarding the estimate of child dental neglect worldwide [11]. Hence, in this study, in addition to recording the caries status, the gingival status i.e. bleeding on probing was also evaluated which interprets the degree of failure to seek dental treatment. Out of 1000 children maximum number of the participants were 7 years with 596 male and 404 females. Majority of the children were in 1st standard and from private school. The caretakers who responded to the questionnaire were mostly mothers of the children. Hence, it helped us to know the complete home and professional dental care the child receives as the child is mostly with the mother. The results of the present study showed that dental neglect was found more in parents who have done only higher secondary education which showed lesser levels of positive dental attitudes which is in contrary to the result of Gurunathan D et al. [12] where it was stated that parents who have done secondary education showed lesser levels of positive dental attitudes which is similar to studies done by Freeman et al. and Williams et al. [13,14]. In the present study, a significant difference was observed in the dental neglect scores among parents residing in the suburban areas in comparison with parents of urban areas. This is essentially due to not much awareness of oral health, availability, and usage of dental services [15]. The dental neglect among children is higher among parents’ whose last dental visit was once or twice in previous 2 years, those who used only school dental services and were symptom driven which is similar to the findings in South Australia and Chennai [16]. The dental neglect is reflected in the poor oral health of these children with significantly higher caries prevalence and untreated carious lesions. This suggests that the knowledge of parents regarding oral health and utility of dental services is limited as the frequency of dental visits suggests the oral health awareness among parents [17].

Conclusion

Inadequate dental care by parents can be observed as dental neglect in children and therefore is a sign of child neglect. Health care workers involved in the care of children are thus in a unique and a very important position to understand early symptoms of child abuse and neglect. We believe and accept that the occurrence of dental caries is an important sign to this diagnosis. From this study it is concluded that, the dental neglect among school going children aged 4-12 years regarding oral hygiene is still far from satisfactory in certain respects in our population, but it is also seen that oral hygiene status can be improved after sessions of oral health education to the children and most importantly the parents.

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Lupine Publishers | Newer Insights in Early Childhood Dental Caries

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Early dental caries is a common devastating disease of early childhood but can be prevented easily by simple methods. It is more common in developing countries and poor socioeconomic status but can be found in all settings. Different bacteria interacting with host salivary molecules, play a role in the development and aggravation of these lesions. Newer techniques for diagnosis, bacterial isolation, as well as treatment are coming up. Clinicians and researchers should be abreast with new developments to ensure proper diagnosis and treatment of these cases.

Keywords: Caries; sugar; cariogenic; streptococcus mutans

Introduction

 Dental caries is a clinical challenge, especially in young children [1]. In fact, it is the commonest chronic infectious disease of childhood, and caused due to interaction or oral bacteria like Streptococcus mutans with sugary foods and saliva [1].  Of all dental caries, Early Childhood caries or ECC can be defined as “the presence of one or more decayed (non-cavitated or cavitated lesions), missing teeth (due to caries), or filled tooth surfaces in any primary tooth in a child 72 of months age or younger [1]. ECC is also called baby bottle-fed tooth decay, early childhood dental decay, comforter caries, nursing caries, maxillary anterior caries and rampant caries [1]. In children younger than 3 years of age, in addition, any sign of smooth-surface caries indicates severe early childhood caries (S-ECC) [1]. Early dental caries is frequently encountered in children of less than 71 months of age. Poor oral hygiene or insufficient dental plaque removal can lead to the rapid progression of ECC [2]. As regards bacterial etiology of dental caries, some strains, such as Streptococcus sanguinis, are reportedly associated with healthy teeth, while others, such as S. mutans, other oral Streptococcus spp., Veillonella spp., Actinomyces spp., Bifidobacterium spp., and Lactobacillus fermentum, were associated with caries [3]. There is also enough evidence that Gram positive bacteria like Actinomyces gerencseriae and other Actinomyces spp. play an important role in caries initiation [3]. In a study by Munson et al, in addition to S. Mutans and Lactobacillus spp., Rothia denticariosa and Propionibacterium acnes have also been found in caries lesions [4].

Epidemiology

ECC affects infants and preschool children worldwide, and its prevalence, though variable, can be up to 85% in disadvantaged groups [5]. Prevalence of ECC also varies widely, depending several variables like race, culture, and ethnicity, socioeconomic status, lifestyle, diet and oral hygiene practices and also according to the regional factors from country to country and from area to area [6]. A review of the literature suggests that in most developed countries the prevalence rate of ECC is between 1 and 12% [6]. In less developed countries and among the disadvantaged or poorer groups in developed countries, the prevalence of ECC has been shown to be as high as 70% [6]. However, it is not restricted to children with low socioeconomic status [2]. Recent data, for example, from Australia show a prevalence of ECC of more than 50% in 6-year-old children with caries on deciduous teeth [7]. Milsom et al. found that children with an already existing caries lesion have a 5–6 times higher incidence of developing new caries lesions compared to previously caries-free children [8]. Sleeping problems and insufficient sleep has also been identified as risk factor for ECC, because sleeping problems lead to more frequent use of night-time bottle use containing sugar-sweetened beverages [9]. There is a relationship with gender, since according to studies, the highest prevalence of ECC is found in the 3- 4-year-old age group; also, boys are significantly more affected than girls, aged between 8 months and 7 years [10].

Risk factors

Many risk factors have been identified like

a) Most of the studies have shown significant correlation between ECC and bottle-feeding and sleeping of the baby with a bottle [1].
b) There is substantial evidence that prolonged and nocturnal breastfeeding is associated with an increased risk of ECC, particularly after the age of 12 months [1].
These aggravate caries due to less saliva production at night and less bacterial clearing.
c) Fermentable carbohydrates are a major factor in the development of dental caries. The small size of these sugar molecules allows salivary amylase enzyme to split the molecules into components that can then be easily metabolized by the bacteria in the plaque [11]. This process leads to bacteria producing acidic end products with subsequent demineralization of teeth.
d) Enamel hypoplasia due to premature birth, low birth weight or malnutrition is also a very important risk factor for caries development [12].

Clinical features

In the initial phases, ECC appears as a dull, white demineralized enamel that quickly progresses to obvious decay along the gingival margin [13]. Primary maxillary incisors are usually afflicted earlier than the four maxillary anterior teeth which are often involved simultaneously [1]. Carious lesions can be found on either the labial or lingual surfaces of the teeth and, sometimes on both [1]. The decayed hard tissue is clinically apparent as a yellow or brown cavitated area [1].

Diagnosis

Diagnosis is clinical. Culture of the bacteria can be carried out in Mitis-Salivations agar, from where colonies can further be identified [14]. However, S. mutans may be slightly inhibited in this medium and S. mitis may need longer incubation [14].

Etiology and Pathogenesis

It has been depicted by Corby et al that some bacteria are associated with healthy or caries –free teeth, like Streptococcus parasanguinis, Abiotrophia defectiva, Streptococcus mitis, Streptococcus oralis, and S. sanguinis [15]. The same group also showed that Actinomyces species, S. mutans, and Lactobacillus spp. were consistently associated with disease [15]. S. mutans and S. sobrinus have been recognized over the years as the main culprits behind development of Early childhood Dental caries [16]. They damage the dental enamel in presence of fermentable carbohydrates like Glucose, sucrose and fructose. In fact, S. mutant is present in about 30% of the plaques in carious teeth compared to 0.1% in healthy teeth [17]. Nowadays, it is well studied that not only bacteria, but also fungi, such as Candida albicans and the interactions between several different microbes, can enhance the progression of caries [18] . Bacteria and other microbes degrade sugars and lead to acid production which causes demineralisation of teeth and caries development [1]. Enamel of deciduous teeth is more vulnerable to acid-mediated damage than permanent teeth because it is thinner and built quickly in about 24 months by ameloblasts than that of permanent teeth which takes about 16 years to be built [19].

Implications

If left untreated, ECC, also called rampant caries, can lead to rapid and complete destruction of the crown [5]. Hence there is need of rapid and accurate diagnosis of the condition and adoption of suitable preventive measures.

Newer developments

New research has unearthed new mechanisms of pathogenesis in ECC. Bacterial biofilms are rapidly produced and are made of exopolymer matrix or EPS. This EPS is formed more on exposure to sucrose and fructose, and lead to further adhesion and colonization by cariogenic bacteria on surface of damaged teeth. This increased formation of biofilm biomass or “visible plaque”, often found on the smooth surfaces of the children at risk of ECC shows the importance of EPS in the pathological process [20]. Research has also demonstrated a few biomarkers or host salivary molecules that affect ECC development. For example, host CSP-1 helps in adhesion of cariogenic bacteria to the enamel [20]. There are 2 types of Proline-rich glycoproteins in human saliva: acidic PRP and basic PRP. Basic PRP helps in ammonia production and neutralise sugar acids, whereas acidic PRPs bind strongly to teeth and enhance adhesion of the cariogenic bacteria [20]. These molecules can be biomarkers to help in assessing prognosis of ECC.

Newer bacterial and other agents

Atopobium vaginale has been found significantly in ECC in those cases that also grow Streptococcus mutans [3]. Bifidobacterium species have been associated with deep caries lesions [21]. In case of severe ECC, Porphyromonas catoniae has been found very commonly in the plaques [22]. Novel techniques like The Human Oral Microbe Identification Microarray (HOMIM) can be used for this type of assessment [22]

Newer options for treatment

Usually Children at low risk generally do not need any restorative therapy [1]. Children at moderate risk may require restoration of the progressing and cavitated lesions, while white spot and enamel proximal lesions should be treated by preventive techniques and then monitored for progression [1]. Children at high risk, however, may need earlier restorative interventions of enamel proximal lesions, and intervention of the progressing and cavitary lesions to minimize continual caries development [1]. Sometimes stainless-steel crown following pulpotomy and pulpectomy may be needed in cases of severe ECC [1].

Prevention

Prevention of ECC should focus on educating the parents about no nocturnal feeding and dietary modification [5]. Parents also should be advocated to maintain optimal dental health during pre- and postnatal periods [5]. Child health professionals, like physicians, assistants of physician, nursing practitioners, and nurses can play a very significant role in reducing the burden of this disease through monitoring, prompt diagnosis and health promotion activities [1]. Prevention of the progress of ECC can be carried out with the help of restorations, diet counselling, educating parents regarding decay-promoting feeding habits, maintenance of good oral hygiene, and the use of preventive agents like topical fluorides [5].

Discussion

ECC is a very common chronic disease of childhood and easily preventable by simple measures [5]. The associated pain from dental caries has got a negative impact on the child’s emotional status, sleep patterns, and ability to learn or perform usual daily activities. A wide range of risk factors are linked with ECC in children from underprivileged and low socioeconomic status [5]. Oral health has been recognized as an essential prerequisite for general health and quality of life. Therefore, both oral disease prevention and oral health promotion should be included as integral components of chronic disease prevention and general health promotion programmes [5].

Conclusion

Early childhood caries should be diagnosed and treated early. New research is showing new avenues of diagnosis and aetiopathogenesis study.

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Lupine Publishers | Cardiovascular Diseases in Children –Oral Findings and Dental Treatment Approaches

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Oral and dental health is of vital importance in children with cardiovascular system disease. Congenital and acquired heart diseases make oral treatment complicate in children and increase the risk of infective endocarditis [1]. The dentists main aim in children with heart disease should be to prevent infective endocarditis, to maintain periodontal health and to ensure a well oral hygiene. In these children, medical history should be taken in detail before dental treatment. Consult with the pediatrician and inform about the condition of the disease and the drugs used recently. Consideration should be given, and antibiotic prophylaxis should be evaluated consultation to in the treatment planning of children with heart disease. In these children, dental treatments should be performed quickly and effectively, and family awareness should be given importance [1-3]. In this review, common oral findings related to cardiovascular system diseases will be discussed and the precautions and treatment approaches of dentist will be mentioned [4].

Keywords: Endocarditis, heart diseases, intraoral findings, pediatric dentistry

Review

Almost all of the heart diseases seen in children are congenital. The most common structural congenital heart diseases are; ventricular septal defect, patent ductus arteriosus, atrial septal defect, fallot tetralogy, pulmonary stenosis, aortic coarctation, aortic stenosis and transposition of the great arteries. Large defects are surgically closed in the first years of life, and some defects may require complex surgical treatment and eventually transplantation. Acquired heart diseases such as myocarditis and infected endocarditis are the cause of disability and death in children [5]. Oral and dental health may be insufficient in children with congenital heart disease. The reasons for this; chronic vomiting in children up to one-year, dry mouth due to drugs used, neglect of oral care due to cardiac problems as the primary priorities of families [1]. Poor oral hygiene in children with heart disease may pose a risk for bacteremia. Infective endocarditis can result with severe valvular dysfunction, dehiscence, congestive heart disease and various embolisms leading to death. In the long term, it may cause cardiac valve damage and prosthetic regeneration of the heart valve [1,6-8].

Oral findings

Oral findings in children with cardiovascular disease include cyanotic gingivitis, stomatitis, glossitis, mucositis, cleft lip and palate, clefts in the tongue, the fungiform and filiform papilla of the tongue becoming dark red [5,9]. In addition, enamel hypoplasia, high incidence of caries, delays in teeth exfoliation, periodontal diseases and intrinsic discolorations are observed [5,9,10]. In particular, discolorations in permanent teeth occur due to the ingestion of blood and blood products by drugs, increased caries activity and poor oral hygiene [5]. Poor oral hygiene, use of drugs, inadequate food and mineral consumption are effective risk factors for the onset of periodontal disease in children with congenital cardiovascular disease [11,12]. Pourmoghaddas et al. [12] reported that children with congenital heart disease had significantly higher periodontitis than healthy children and that periodontal disease caused endocarditis risk. Al Alousi et al. [13] reported that the rate of development of enamel defects was high in patients with ventricular septal defect and was observed due to malnutrition. The researchers stated that nutrient elements may affect the epithelial cell function and mineralization process and prepare the ground for defect formation in enamel hypoplasia [13]. In Fallot Tetralogy, wrinkled tongue is observed as an oral finding [1].

Infective endocarditis

Infective endocarditis is a rare disease that results in high morbidity and mortality, with an annual incidence of 0.05- 0.12/1000 in children [3,14,15]. Turbulent blood flow observed in heart diseases leads to endothelial injury, resulting in storage of platelets and fibrin on the endothelial surface [15]. As a result, non-bacterial thrombotic endocarditis occurs and bacteremia results in the adhesion of bacteria to this injured endocardium and proliferation in vegetation leading to infective endocarditis. Therefore, some heart diseases pave the way for the development of infective endocarditis [14,15]. Invasive dental procedures, gastrointestinal and genitourinary systems related operations may cause bacteremia and infective endocarditis [15].

Bacteremia in dental procedures

In children, oral flora changes and streptococci (alpha hemolytic streptococci), actinomyces and privately species increase after infancy and begins to resemble adult flora. Healthy children have streptococci, staphylococci, neissera and haemophilus species, while older children have bacteria such as capnocytophaga and aggregatibacter actinomycetemcomitans, which cause periodontal disease [15]. The host’s response to dental plaque due to poor oral hygiene is gingivitis. When this inflammation develops, bacterial colonies may become involved in the gum capillary circulation due to thinning and ulceration. Therefore, there is a risk of bacteremia even in minimal procedures such as daily tooth brushing The frequency of bacteremia after toothbrushing and flossing has been reported to be 20-68%, 20-40% after tooth cleaning with toothpicks, 7-50% after mouth rinsing, and 7-51% after chewing food [3]. In addition, 10-100% after tooth extraction, 36-88% after periodontal surgery, 8-80% after removal of dental plaque, 9-32% after plastic matrix placement, 20% after endodontic procedures have been reported to develop bacteremia [3]. Good oral hygiene and prevention from diseases (such as gingivitis, tooth decay) are important to minimize the risk of bacteremia [15]. The use of amoxicillin in the selection of antibiotics in dental procedures has been shown to have a statistically significant effect on reducing the incidence and duration of bacteremia.

While previous American Heart Association (AHA) guidelines recommend antibiotic prophylaxis for all dental interventions that may cause bleeding, this recommendation has been altered since there is no evidence that this is a predictive symptom of bacteremia when bleeding occurs during dental procedures [3]. In the latest guidelines published by AHA, it was decided to administer prophylactic antibiotics only to the highest-risk group before invasive dental procedures [3] (Table 1). Prophylactic antibiotic administration is recommended only if high-risk patients are scheduled for an operation to the gingival tissue or the periapical region of the tooth, or if there is a risk of mucosal perforation. Routine injections of anesthetic agents, x-rays, removable dental prostheses, orthoses, orthodontic material placement, prosthesis matching, primary tooth extraction, antibiotic prophylaxis are not recommended in uninfected tissue [3]. Antibiotic prophylaxis should be given 30-60 minutes before the procedure. However, it can be given within 2 hours after the procedure if it is not given before the procedure [3]. In patients using oral anticoagulants, intramuscular injection should be avoided, and oral antibiotics should be preferred. Clindamycin, clarithromycin, azithromycin should be given to patients who routinely use antibiotics as they may be resistant to penicillin and ampicillin [3]. These patients should receive dental treatment 10 days after antibiotic treatment to normalize oral flora. In patients receiving intravenous antibiotic therapy, the antibiotic dose should be adjusted 30-60 minutes before dental intervention [3,16] (Tables 1&2).

Table 1: High-risk patients in whom infective endocarditis prophylaxis is recommended [16].

Table 2: Antibiotic prophylaxis recommended before dental procedures [16].

Dentist approach

Patients with cardiovascular disease should be consulted with their doctors. Deciding on premedication, preoperative antibiotic requirements, anesthetic selection and surgical procedures should be decided in accordance with the recommendations of the physician of patient. In children diagnosed with cardiovascular disease, a preventive program including nutritional advice, fluoride therapy, fissure sealants and oral hygiene should be applied [1]. Arrhythmia due to endogenous catecholamines triggered by stress, fear and pain may develop during dental procedures, and patients who are prone to arrhythmia should be closely monitored [3]. Antibiotic prophylaxis should be performed in high-risk patients if a procedure is planned for the gingival tissue or the periapical region of the tooth, or if there is a risk of mucosal perforation [3]. Dental procedures in high and medium risk groups should not exceed the treatment of deep dentine caries. Direct pulp capping, pulpotomy and root canal treatments are not indicated because they increase the risk of bacterial endocarditis. In very deep decayed teeth, the treatment option should be extraction [1].

Conclusion

In children with cardiovascular disease, the risk of infectious endocarditis and bacteremia due to the risk of fatal outcome of the heart valve is very important in terms of oral and dental health in these patients. It is very important for dentists to consult with their physician before dental procedures in children with heart disease, and to take prophylaxis needs and stress tolerances of their patients by writing. These children and their families should be adequately informed about oral hygiene. In this way, the risk of bacteremia, even in oral cleaning procedures such as chewing and brushing, can prevent infective endocarditis [1].

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Lupine Publishers | Association of Mother’s Genetic Sensitivity to the Taste of 6-N-Propylthiouracil (Prop) and Their Children’s Dental Caries Status in Nepal

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Introduction: Dental caries is a multifactorial disease and is one of the most prevalent infectious disease that affects mankind. Young children present a unique risk for dental caries as their host-defense systems and bacterial flora are in the process of being developed and also because the newly erupted tooth surfaces are more susceptible to dental caries. Mothers are the persons who generally influence their children via their own food preferences. Hence the mother’s taste perception plays an important role in the development of dental caries in their children. The need of this study is to examine the association of mother’s taste perception to 6-n-propylthiouracil with caries prevalence in their young children as well as with other caries risk determinants such as mothers and their children’s oral hygiene practices.

Material and Method: 180 pair of mothers and their children in the age group of 3 to 6 years of both sexes were selected for the study & 6-n-propylthiouracil testing is done. A trained and calibrated examiner who did not have any knowledge of the mother’s PROP test performed a comprehensive clinical examination of the children to determine the presence or absence of DMFT/dmft.

Results: It is observed that nonstarter mother and children have higher caries prevalence than medium tasters and supertasters. Discussion- Genetic sensitivity to taste is an inherited trait in children from their parents, inheritance from mother being more pronounced.

Conclusion: Dental caries is multifactorial. No significant correlation between susceptibility of mother and child to genetic sensitivity exists, and genetic sensitivity is not the only criteria for severity.

Keywords: 6-n-Propylthiouracil; dental caries; dietary habits

Introduction

Dental caries is a multifactorial disease and is one of the most prevalent infectious disease that affects mankind. The development of dental caries depends on several critical interactions between a susceptible tooth surface, oral bacteria, fermentable carbohydrates and frequency of consumption of sugar [1,2]. Young children present a unique risk for dental caries as their host-defense systems and bacterial flora are in the process of being developed and also because the newly erupted tooth surfaces are more susceptible to dental caries [3]. Parents must also negotiate the dietary transition from bottle feeding to solid food and also take into consideration the child’s tastes. Several risk factors such as salivary counts of mutant’s streptococci, past carious experience and frequency of sugar intake have been evaluated to identify children at high risk of caries [1,4-7]. However, none of the currently available caries screening methods can identify children at high risk of caries quite effectively [1,8].

The role of diet as a direct cause of dental caries has been extensively reported [1,4,9,10]. A high intake of sugar has been correlated with a high dental caries in pre-school and school aged children. A high sugar intake reflects a preference for a sweet substance. Genetic sensitivity to taste may be associated with a preference or no preference of some food by children. Sensitivity to taste is an inherited trait in children [1,11]. In 1991 it was found that there is a genetic variation in the ability to taste the bitterness of the chemical 6-n-propylthiouracil (PROP) [1,12]. This variation was found to be associated with food preferences in children. Fox in 1931 found that some individuals perceived chemicals related to PROP as bitter (supertaster) while others could hardly perceive them at all (nonstarter). Those who are PROP super taster are typically supertasters in general and tend to dislike sweet while those who are PROP none tasters like sweet food and prefer strong tasting food products. Mothers are the persons who generally influence their children via their own food preferences. In many households’ mothers generally reward their children using sugary snacks which might increase their children’s preference for that kind of food. Hence the mother’s taste perception plays an important role in the development of dental caries in their children. This study was carries out with following aims and objectives:

Aim

To find the association between mother’s sensitivity to 6-n-propylthiouracil (PROP) and their children’s dental caries status

Objectives

To compare mother’s and child’s oral hygiene practices with their dental caries status. To determine the taste quality and taste preferences of food products among these study groups.

Materials and Methods

220 pairs of mother and children were randomly selected from consecutive children who were accompanied by their mothers visiting the Department of Pedodontics and Preventive Dentistry in the institution. Out of these 220 pairs of mother and children 180 pairs fulfilled the inclusion criteria. A single trained and calibrated examiner who did not have any knowledge of the mother’s PROP test performed a comprehensive clinical examination of the children to determine the presence or absence of DMFT/dmft. All examinations were performed with a mouth mirror and explorer in a lighted operatory after taking consent from the mother. Demographic information of mothers, their oral hygiene practices, their oral health status and the presence of grandparents in the household was collected by an open-ended questionnaire. A second questionnaire was used to collect data regarding the oral hygiene and feeding practices of the child (e.g. frequency of tooth brushing, intake of sugary food and frequency of intake of sugary food).

Inclusion Criteria

For children

a) Age groups of 3 to 6 years.
b) ASA physical status I/II and stable mental condition
c) Should be accompanied by mother.

For mother

a) Participant cooperation and acceptance of the study programmer.
b) Should be healthy and mentally stable.
c) Should be literate.

Exclusion Criteria

For children

a) Should not be less than three years and not over six years
b) Should not have any medical / hereditary conditions.
c) No acute dental diseases.

For mothers

a) Should not be pregnant
b) Should not suffer from systemic diseases
c) Should not be allergic to 6-n-propylthiouracil (PROP)
d) Should not be under any medications that could alter the taste sensation and affect salivary flow.

Prop testing

Figure 1: Filter paper with PROP solution.

single examiner who did not have any knowledge of the mother’s and children’s oral health status had conducted the PROP test on the mothers. A small piece of filter paper (2 cm circle of Whatman’s grade 1 filter paper) containing approximately 1.6 mg (measured by calibrated dropper) of 6-n-propylthiouracil (PROP) was used to determine each mother’s taste type (Figure 1). The mother was asked to put the piece of filter paper in the mouth and moisten it with saliva for 30 seconds (Figure 2). After removing the filter paper, the mother was asked to quantify the intensity of bitter taste on the modified Green’s scale and was classified of supertasters (>60), medium tasters (12-60) and no tasters (<12). All examinations and PROP testing were carried out at the same time of the day (mid-morning) throughout the study. All the data gathered was tabulated and statistically analyzed. Student’s paired t test and chi square test was done.

Figure 2: PROP test on mother.

Figure 3: Distribution of population (children) according to gender.

Figure 4: Distribution of taster among mother.

Figure 5: Distribution of oral hygiene practices among children.

Figure 6: Distribution of oral hygiene practices among mother.

Figure 7: Distribution of sugar consumption by children from their grandparents.

Figure 8: Association of children of supertaster & non taster mothers with sweet food.

Figure 9: Association of supertaster & Non taster mother with sweet food.

Figure 10: Distribution of mean DMFT/dmft score of supertasters, non-taster mothers and their Children.

Table 1: Association of supertaster & non taster mothers and their children with sweet food.

Table 2: Distribution of mean DMFT/dmft score of supertasters, non-taster mothers and their Children.

Discussion

The present study comprised of 180 pairs of mother and child. The mothers were subjected to PROP testing and classified into super tasters, medium tasters and non-tasters according to the Green’s labeled magnitude scale. The mothers who were super tasters found the taste of PROP to be extremely bitter and the non-taster mothers described the taste of PROP to be tasteless while the medium taster mothers failed to categories the taste of PROP. The super taster mothers perceived the taste of PROP in lower concentration (1.6 mg per ml). This may be due to the presence of high-density fungiform papilla and taste receptors in the tongue compared to medium tasters and non-tasters. This may make the super taster mothers dislike sugary food. Mothers being the primary care givers to children influences the food habit of children. Mothers who prefers sugary foods are more likely to prepare and feed their children the same then those who do no prefer sugary food. In our study it was found that the mean dmft/ DMFT score among non-taster mothers (1.32) and their children (1.27) was higher than the mean dmft/ DMFT of super taster mothers (0.17) and their children (0.16) respectively. The influence of grandparents in the family cannot be neglected. Even in children of super taster mothers, 23 children reported they were given sugary snacks by their grandparents regularly while 47 children of non-taster mothers reported the same.
The pampering of grand parents may also be a causative factor for dental caries in children. The finding of the present study also showed that children who brushed their teeth once or twice per day experienced more dental caries if their mothers were non tasters whereas children of super tasters had less dental caries. This can be explained by the frequent intake of sugary food in case of children of non-taster mothers and also may be influenced by the food prepared by their mothers. Similarly, mothers who were non tasters had a higher dental caries experience than the super taster mothers. This may be due to their increased susceptibility to sugary food. In the present study when the super tasters and non-taster mothers were asked about their liking for sugary food, majority of the super taster mothers (64) stated that they did not prefer sweet food, while 95 non taster mothers stated that they preferred sugary food. In case of the children of super taster and non-taster mothers, the results were significant. The mother’s dietary habits and tastes probably affected the oral health status of the child. When the association between the preference of sugary food in super taster and non-taster mothers and their children was seen, it was found that the children of super taster mothers did not prefer sugary food while it was vice versa for the children of non-taster mothers. This may be due to genetic factors and also might be due to the dietary habits of the mothers which influenced the dental caries status of their children.

Conclusion

In the present study, the results suggested that the children of the mothers who are non-tasters or who prefers sweet food have higher dental caries experience. Factors such as the presence of grandparents in the household, frequency of brushing, preference of food and dietary habits may play an important role in the development of dental caries in children. Thus, mother’s genetic sensitivity to the bitter taste of prop can be used as a useful adjunct to identify children who are at risk of developing dental caries.

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Lupine Publishers | The Time Has Come for Pediatric Dentistry and Medicine to Develop A New Thought Process, Rather Than Just Thinking Outside the Box When Caring for Newborn Babies and Infants, We Need A Totally New Box

 Lupine Publishers | Journal of Pediatric Dentistry

Introduction

The concept of thinking outside the box is no longer valid, we now need to create a new box. The volumes of research showing the merging of medicine and dentistry is growing rapidly and those who fail to grasp its importance will be left behind. Our primary goal in caring for newborn infants and babies should be to allow them to grow and develop to their maximum potential. It’s time for the old, outdated conservative ideas, to be shed and have the Dental and Medical community understand that the separation of medicine and dentistry is rapidly disappearing.

Collaboration does not turf concerns

The primary example of this is in the diagnosis and treatment of tethered oral tissues also known as TOTS. In the early 1970’s less than 22 % of US women were breastfeeding their newborn infants, many who were, did so because they could not afford the cost of infant milk formulas [1]. The formula industry has always advertised the benefits of their product over mother’s milk and since so few mothers were nursing, difficulties of nursing due to tongue or lip ties were dismissed or just plain ignored by the medical providers. Today, we have over 80% of mothers breastfeeding , we also are aware of the many long-term benefits for both the infant and mother. We also know that mothers who wish to breastfeed include all socioeconomic levels of society. It is not a fad as many in the medical community refer to treatment of TOTs.
Yet, the medical community still all too often rejects the idea that TOTS do prevent a baby from achieving a good secure attachment to a mother’s breast, resulting in a plethora of symptoms for both mother and infant, often resulting in the mother giving up and using a bottle. Some explain this failure of the Medical community to embrace the release of these TOTS as overstepping our scope of practice and consider it their turf, yet they do nothing. The effects of TOTS begin in the oral cavity, where we as pediatric dentists, are the experts. Improving the health care of mothers and infants and should not involve turf wars and protectionism for physicians and dentists. We need to effectively join forces to create a successful breastfeeding outcome. Dentistry and medicine treat the same entity, where often one or many health problems can overlap into both professions’ territory. This is a key reason why Medicine needs to develop a cooperative team approach to breastfeeding issues with Dentists [2,3]. The understanding in treating infant oral health is growing and changing, this presents an excellent opportunity for physicians and dentists to find ways in to effectively join forces to create a successful breastfeeding outcome.

Infant- Mother Bonding

It is time to look beyond just the infant’s latch, but the actual potential complication that a poor latch creates beyond the act of breastfeeding comfortable for the Mother. Medicine recognizes the term attachment theory, which states that the babies initial bonding with the mother lasts a lifetime, if it is short circuited, the mother may develop signs of post-partum depression, which rather than treating symptoms pharmacologically, in many cases this may be resolved if we , as pediatric dentists can fix the inability of the infant to latch onto the breast by a simple in office surgical release, not just a simple snip, known as a frenectomy [4]. Breastfeeding plays an integral role in forming the deep attachment between mother and baby.

Failure to thrive

Infants are far too often placed in hospitals for failure to thrive, parents are occasionally subjected to Child abuse accusations because their child appears malnourished, and in severe cases have had nasal-gastric or tubes inserted directly into the stomach surgically to literally force feed infants [5]. All this has happened because the physician, pediatrician, ENT or GI doctors never even consider the ankylosed tongue as the primary cause.

Brain growth and development

The window of opportunity to help many babies may close with-in the first 90 days after the infant’s birth [6]. Studies indicate that a baby’s brain grows by 1 percent each day beginning right after birth. A newborn brain grows extraordinarily fast right after birth but slows down to a growth rate of 0.4 percent per day by the end of three months. An infants’ brains grow by 64 percent in the first 90 days, according to the study. The average brain size was 20 cubic inches (341 cubic centimeters) at birth, and 34 cubic inches (558 cubic cm) at 90 days. Simply stated, the brains of newborns grew from about 33 percent of the average adult brain doubles in size in the first year, and by age three it has reached 80 % of its adult volume.

Air induced reflux

It was those hellish hours between darkness and dawn when my husband and I would take turns walking around the house with our baby inn our arms, praying and, mostly in my case, sobbing because we couldn’t console our baby. Infants suffering from reflux are still being treated with adult anti-reflux drugs rather than looking a t the most likely source of gas build up, the swallowing of air during the infant’s latch due to a poor latch and seal onto the mother’s breast. Adult pharmaceuticals such as Peracid and Nexium are not approved drugs for children under age one [7-10]. Studies show they are not effective. Yet the use is skyrocketed in recent years. Simply releasing TOTS will allow a good secure latch to occur in most infants, quickly resolving the issue. Medications like ranitidine (Zantac) or omeprazole (Prilosec) can prevent absorption of calcium and iron and increase the risk of certain intestinal and respiratory infections. Children who used PPIs had a 22% increased likelihood of fracture, while children who used both PPIs and H2-blockers had a 31% increased likelihood of fracture.

Sleep disordered breathing

Tethered oral tissues (TOTS) is also a common undiagnosed source of obstructive airway problems, obstructive sleep apnea and reflux in infants and newborns [11-16]. The American Academy of Pediatric Dentistry (AAPD) recognizes that obstructive sleep apnea (OSA) occurs in the pediatric population. In order to reduce such complications, AAPD encourages healthcare professionals to routinely screen their patients for increased risk for OSA and to facilitate medical referral when indicated The most common form of Pediatric OSA is a disorder of breathing characterized by prolonged, partial upper airway obstruction and or intermittent/ complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns. These cycles of awakening prohibit the infant as well as toddlers having apnea from reaching deep, restful sleep. For this reason, children with untreated OSA may be inappropriately diagnosed as having ADHD. Often the ankylosed tongue is again ignored and not considered as a part of a differential diagnosis. Findings from studies that used complementary research methods have converged to strongly suggest that inadequate sleep quality and quantity are causally linked to sleepiness, inattention, and probably other cognitive and behavioral deficits that impact daytime functioning, with potential implications for long-term development.

Conclusion

It has been stated that it can take a 17-year lag to change and understand traditional research. This lack of knowledge puts those responsible for enabling new research at a disadvantage [17]. A staggering 36,000 randomized controlled trials (RCTs) are published each year, on average, and it typically takes about 17 years for findings to reach clinical practice [18]. We do not have this time to waste in treating our infants and newborns. We need to establish a good collaboration and trust between our two professions and develop a good understanding of how tethered oral tissues can have a significant impact on the overall growth and development of newborns and infants [19].

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Lupine Publishers | Anterior Open Bite Using Simões Network in Growing Patient: A Case Report

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

The anterior open bite is characterized by the negative vertical overhang occurring in the anterior region. It consists of a discrepancy in the vertical direction and is one of the malocclusions with greater aesthetic-functional impairment, besides dental and skeletal alterations. It has a high prevalence in the deciduous and mixed dentition and its etiology is multifactorial, highlighting the deleterious oral habits as the most prevalent. The objective of this study was to present the clinical case of a growing female patient presenting an anterior open bite associated with thumb sucking, by means of treatment with the functional orthopedic device Simões Network (SN3). During the first 12 months follow-up, we observed facial and intraoral oral changes and forward, the improvement of functional and craniofacial relationships, observed through complementary tests.

Keywords: Open Bite; dentition, mixed; orthopedics

Introduction

The balance of soft tissue growth and facial changes are important for the craniofacial development. Mineralized bone is formed through a process known as ossification by the membrane activity providing the function of remodeling and displacement. Breath, chewing, phonation and swallowing functions are prior to the regular growth development [1]. Thumb or pacifier sucking, and tongue thrusting may cause a disorder knowing as an anterior open bite. The severity of the malocclusion will be according to the magnitude, frequency and time of the habit [2]. Prolonged breastfeeding will be recommended to avoid nonnutritive sucking habits, as the sucking of fingers, pacifiers and bottle feeding [3,4]. Anterior open bite (AOB) is defined as the lack of incisal contact between anterior teeth in centric relation. AOB creates aesthetics problems, speech disorders and tongue thrusting habit [5]. This malocclusion requires early treatment due to all the etiological factors mentioned before. The stability will be achieved in a long term; thus, the pediatric dentist must be alert and minimize the problem as soon as possible in attempt to decrease the time of the treatment and to maintain the stability 5. The auto correction index is low when the correct habits are achieved [6,7]. The prevalence in the population ranges from 1,5% to 11%. Some authors also describe that 17% to 36% of those seeking orthodontic treatments feature AOB [8-11]. This malocclusion may also occurs due to a skeletal component classified open bite into dental and skeletal, associated with excessive molar height, divergent upper and lower occlusal planes, steep mandibular plane angle, increased gonial angle, short mandibular ramus, downward rotation of posterior part of the maxilla or palatal plane tipped up anteriorly, increased lower anterior facial height and decreased upper anterior facial height. According to severity, modalities of treatment are required: growth modulation; orthodontic mechanotherapy and the combination with orthognathic surgery [12-14]. Orthopedics devices is a therapy to readapt the muscular system which is very efficient in growing patients resuming the facial balance [15]. This article presents a clinical case of growing female patient, with anterior open bite treated with the functional orthopedic device Simões Network (SN3) [16].

Case Report

A female patient, 8 years and 4 months of age, melanoderma, came for treatment at the Postgraduate Course in Orthodontics of Brazil University (São Paulo, SP, Brazil). A facial analysis detected convex facial profile, lack of lip closure, and a decrease in nasolabial angle (Figure 1). The patient exhibited thumb sucking habit, mixed breathing, atypical swallowing and speech. shows angle class II malocclusion, 6 millimeters of an anterior open bite, mild crowding and a supernumerary Figures 2&3 tooth in the anterior lower jaw with mandibular midline deviation to the right. Cephalometric Rx shows proclined upper incisors due to the thumb sucking the objetives

Figure 1: Convex facial profile, a decrease in nasolabial angle and the upper lip covering the incisor.

Figure 2: Anterior open bite, mild crowding and a supernumerary tooth in the anterior lower jaw and proclined upper incisors.

Figure 3: Angle class II malocclusion, supernumerary tooth in the anterior lower jaw and an 6mm open bite.

for the first phase of the treatment were to eliminate the thumb sucking, the open bite, dental deviations, provide arch expansion and the extraction of the supernumerary tooth.

Treatment Progress

A removable appliance known by Simões Network (SN3) composed with a stainless steel bimaxillary grid (“lower winglets model”) that simulates the incisors occlusion and provides the correct tongue position [15] (Figure 4). The screw was expanded with one-quarter turn biweekly. After 3 months of the treatment beginning o, we added a lip bumper to improve lip seal (Figure 5). We recommended the use for 10 or 12 hours a day. The supernumerary extraction was performed 7 months of the treatment beginning. Figure 6 shows the final of the first stage. Figure 7 shows Angle class I malocclusion and Figure 8 shows the Cephalometric and panoramic Rx after 23 months with the orthopedic appliance. Cephalometric superimposition (Figure 9) and analysis (Table 1) indicated dentoalveolar open bite pretreatment and the correction posttreatment.

Figure 4: SN3 appliance, bimaxillary anchorage with “lower winglets model”.

Figure 5: A lip bumper was added to improve lip seal.

Figure 6: The correction of open bite and the improvement of the alignment.

Figure 7: The arch expansion and molar Class I.

Figure 8: Cephalometric and panoramic Rx after 23 months of treatment.

Figure 9: Cephalometric superimposition revealed maxillary incisor retrusion and mandibular incisor in normal bite.

Table 1: Summary of cephalometric measures.

Discussion and Conclusion

According to the authors, AOB is a challenge daily faced because and it can result speech and swallows’ problems, tongue posture and imbalance between jaw postures [17-19]. Bonna 2016 alerts that the orthodontics or orthopedic devices are fundamental but without family support the habit suppression will not be achieved [20]. The objective for the first phase of treatment were to eliminate thumb sucking, open bite and arch expansion with orthopedic appliance Simões Network SN3 and after a lip bumper was included to improve seal lip. These goals were achieved during the first stage. Graphic 1 shows best fit reduction open bite from May to November 2017. Even pubertal increments offer best time for orthopedic treatment helping determine the predictability, growth direction, patient management and total treatment time, we did not wait to treat because the disadvantages of the open bite [21]. This reported case was successfully treated with SN3 remained stable after the AOB correction. For the second phase with fixed orthodontic treatment will be necessary [22-29].

Graphic 1: Closure open bite variation during time.

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