A Clinical Study of the Oral Condition of Paediatric Liver Graft Recipients

The liver transplantation procedure was first carried out in 1967 and, since that time, survival rates have been steadily improving. The introduction of the split liver graft procedure has now made liver transplantation available to babies under 1 year of age for the first time. This study is the largest in the world into the oral condition of paediatric liver graft recipients, it was carried out between 1992 and 1996 and contains five separate prospective clinical investigations. It has already been reported that there is a high prevalence of intrinsic pigmentation, enamel hypoplasia, delayed eruption and cyclosporin-induced gingival overgrowth in children with liver grafts. However, the previous studies are few and the number of children in the samples were small. Therefore, the impact of both the increased availability of liver grafts to babies and the improved survival of liver graft recipients on the future paediatric dental need of these children is still to be fully ascertained. Paediatric liver graft recipients also have a high nutritional demand both before and after liver grafting but, in spite of this, they have been shown to 'catch-up' on their peers one year after liver grafting. The effect of malnutrition on the eruption of the primary dentition and whether the same 'catch-up' growth occurs has never been investigated. The bioavailability of cyclosporin is already highly variable, especially in liver graft recipients, and is likely to be further compromised in babies and infants who receive a split liver graft due to poorer absorption. The effect of age, age at the time of transplantation and duration of cyclosporin therapy not only on the prevalence and severity of gingival overgrowth but also on the erupting primary dentition also merits investigation. Organ transplant recipients also have a higher risk of cytomegalovirus infection than the general population. It has recently been suggested that there is a link between cytomegalovirus infection and cyclosporin-induced gingival overgrowth. However, this has never been the subject of a clinical investigation. In the first study, fifty-five paediatric liver graft recipients, who represented a cross- section of the children who attended the Liver unit at Birmingham Children's Hospital, were examined. Thirty-seven of the children were below 5 years of age. Forty-seven percent of the study group had intrinsic pigmentation but only 11% were found to have enamel hypoplasia. The prevalence of delayed eruption was found to be in excess of 40%. Fifty-five percent of the children had gingival overgrowth. There was a significant inverse relationship between the duration of cyclosporin therapy and the trough cyclosporin concentration but analysis of variance failed to show any association between the trough cyclosporin concentration and the severity of the gingival overgrowth. In the second study, thirty-seven children with liver grafts who had intrinsic pigmentation of the dental hard tissues were examined and the severity of the intrinsic green pigmentation measured using a specially developed colour scale. The primary molar teeth were the most severely discoloured but the results of this investigation also suggest that the permanent incisors and first permanent molars are also likely to be similarly, if less severely, affected. The clinical evidence suggested that the deposition of the green pigment was incremental in nature and occurred in the immediate postnatal period. The study also found that the severity of the pigmentation did not to improve with time. The third study was a controlled study that compared the effect of malnutrition, the underlying liver disease, and cyclosporin medication in the aetiology of delayed eruption of the primary dentition. This study confirmed that the prevalence of delayed eruption of the primary dentition in children with liver grafts was 43%, and 48% in those who also had malnutrition. Children with liver grafts had significantly fewer teeth than their age-matched controls with liver disease. There was a highly significant association between the trough cyclosporin concentration and the number of teeth in liver graft recipients who did not have malnutrition. The results showed that malnutrition alone was not a significant aetiological factor. This findings suggest that cyclosporin caused delayed emergence of the primary dentition when there had previously been delayed eruption due to severe liver disease. In the fourth study, ninety-seven paediatric liver graft recipients were examined and the study population was divided into groups according to age, then by age at transplantation and by duration of cyclosporin therapy. The results showed that the prevalence of cyclosporin-induced gingival overgrowth varied with the age of the study sample

Molar incisor hypomineralisation: Teaching and assessment across the undergraduate dental curricula in the UK.

No consensus exists on how molar incisor hypomineralisation (MIH) should be covered by the undergraduate dental curricula. To assess the current teaching and assessment of MIH in the UK. A piloted questionnaire regarding the teaching and assessment of MIH was disseminated to paediatric, restorative and orthodontic teaching leads in each UK dental school (n = 16). Data were analysed using descriptive statistics, chi-squared and Kruskal-Wallis tests. Response rates from paediatric, restorative and orthodontic teams were 75% (n = 12), 44% (n = 7) and 54% (n = 8), respectively. Prevention of caries, preformed metal crowns, anterior resin composites and vital bleaching were taught significantly more by paediatric teams (p = .006). Quality of life and resin infiltration were absent from restorative teaching. Orthodontic teaching focussed on the timing of first permanent molar extractions. Paediatric teams were mainly responsible for assessment. Risk factors, differential diagnoses for MIH and defining clinical features were more likely to be assessed by paediatric teams than by others (p = .006). All specialities reported that students were prepared to manage MIH. Molar incisor hypomineralisation is primarily taught and assessed by paediatric teams. No evidence of multidisciplinary or transitional teaching/assessment existed between specialities. Developing robust guidance regarding MIH learning in the UK undergraduate curricula may help improve consistency

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines

Introduction: There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS). Methods: This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques. Results: From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non‐pharmacological). Conclusions: This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients

Behaviour support in dentistry: A Delphi study to agree terminology in behaviour management

Objectives: Dental behaviour support (DBS) describes all specific techniques practiced to support patients in their experience of professional oral healthcare. DBS is roughly synonymous with behaviour management, which is an outdated concept. There is no agreed terminology to specify the techniques used to support patients who receive dental care. This lack of specificity may lead to imprecision in describing, understanding, teaching, evaluating and implementing behaviour support techniques in dentistry. Therefore, this e‐Delphi study aimed to develop a list of agreed labels and descriptions of DBS techniques used in dentistry and sort them according to underlying principles of behaviour. Methods: Following a registered protocol, a modified e‐Delphi study was applied over two rounds with a final consensus meeting. The threshold of consensus was set a priori at 75%. Agreed techniques were then categorized by four coders, according to behavioural learning theory, to sort techniques according to their mechanism of action. Results: The panel (n = 35) agreed on 42 DBS techniques from a total of 63 candidate labels and descriptions. Complete agreement was achieved regarding all labels and descriptions, while agreement was not achieved regarding distinctiveness for 17 techniques. In exploring underlying principles of learning, it became clear that multiple and differing principles may apply depending on the specific context and procedure in which the technique may be applied. Discussion: Experts agreed on what each DBS technique is, what label to use, and their description, but were less likely to agree on what distinguishes one technique from another. All techniques were describable but not comprehensively categorizable according to principles of learning. While objective consistency was not attained, greater clarity and consistency now exists. The resulting list of agreed terminology marks a significant foundation for future efforts towards understanding DBS techniques in research, education and clinical care