October 29, 2007

Pediatricians Play Critical Role in Children’s Oral Health
Surgery for Epilepsy Focuses on Small Areas of the Brain
Taking it to Extremes: New Sports are Dangerous
New Definitions for Overweight, Obesity Recommended

Pediatricians Play Critical Role in Children’s Oral Health

Pediatricians can play a critical role in children’s oral health by advising parents on ways to prevent dental disease, recognizing the early signs of tooth decay and referring children for proper dental care.

Sunday’s Plenary Session lecture “Pediatricians and Children’s Oral Health” provided insights into the pathogenesis of dental caries and ways to identify signs of worsening disease that could cause facial swelling and infections that spread to the rest of the body.

“Dental caries is a transmissible disease,” said James J. Crall, DDS, ScD, professor and chair of pediatric dentistry at the University of California, Los Angeles, and director of the Maternal Child Health Bureau’s National Oral Health Policy Center.

“The mother is usually the primary source of the infection through vertical transmission. It’s also been shown that caretakers who spend many hours with the child during the day can transmit bacteria from their mouth that can lead to cavities,” he added. Bacteria that cause tooth decay are generally transmitted from mother to child even before the child has teeth.

“When the bacteria are transmitted early on, they are on the epithelial and mucosal surfaces, but once the teeth erupt in the mouth, they attach to the biofilm and solid structures,” Dr Crall explained.

He defined dental caries as a complex, chronic and progressive disease process that leads to tooth decay, but is not the tooth decay itself.

“Simple measures targeted toward one aspect of this disease are not likely to have a large impact. It’s complex in the sense that it is multifactorial, and it’s chronic in the sense that as long as you have a tooth in your mouth, you’re at risk for this disease throughout the course of a lifetime,” Dr Crall said.

Dental caries is diet-dependent, mediated by both the composition and amount of saliva in the mouth, highly prevalent in children and reversible up to a point before it causes significant damage.

“It is a disease, fundamentally, that can cause cavities in the teeth, but it also has significant consequences for children’s general health and quality of life,” Dr Crall stressed. “I tell dental students to think about caries as being similar to diabetes. It’s a chronic disease, and absent substantial lifestyle changes, it’s a progressive, destructive disease. If it spreads beyond the teeth, it can cause damage to other structures of the body.”

Dr Crall described what he referred to as a dynamic balance between a set of risk factors for caries and protective factors against caries.

“The risk factors are those things that promote loss of minerals from the teeth, that is, demineralization, or tooth decay,” he said.

Risk factors include frequent exposure to refined sugars; the presence of cariogenic bacteria, such as Streptococcus mutans, in the mouth; and reduced salivary flow.

“We know that Streptococcus mutans is the primary culprit. It is very efficient at producing acid, and it has an ecological advantage in that it can survive in an acidic environment much better than other forms of bacteria,” Dr Crall said.

“On the protective side, first and foremost we have various kinds of fluorides — water fluoridation, fluoride in toothpaste,” he said, adding that plaque control through daily brushing is another protective factor.

Saliva is a protective factor, but medications used to treat some childhood diseases can affect the quality and composition of saliva in the mouth “in ways we don’t fully understand,” and the medications may also have a high sucrose concentration, Dr Crall said.

“More recently, we’ve been thinking about going beyond fluorides to use various types of antimicrobials — things like chlorhexidine or iodine — to try to achieve an alteration of the bacteria in the mouth,” he said.

The early clinical signs of dental disease are white spots, or enamel caries, on the teeth along the gum line or between the teeth.

“These enamel caries are confined to the outer part of the enamel, but if we don’t stop the disease within the enamel, it progresses into the dentin layer,” Dr Crall said.

“If we don’t stop it at that stage, largely through restoration and trying to re-establish the [bacterial] balance, that process moves to the pulp, which is part of the neurovascular system,” he explained.

Signs of advanced stages of caries disease include widespread tooth decay and swelling in the face.

“Then that infection begins to spread within the body,” Dr Crall said.

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Surgery for Epilepsy Focuses on Small Areas of the Brain

Surgery to treat epilepsy began in the 1960s with large-scale procedures to remove significant portions of the brain by lobectomy, quandrantectomy, or hemispherectomy, but modern surgical approaches to children with medication-refractory epilepsy focus on removing as little tissue as possible.

That message came from Sunday’s Plenary Session lecture, “Lessons from the Surgical Management of Epilepsy,” given by Colin M. Roberts, MD, assistant professor of pediatrics and neurology, and director of the Childhood Epilepsy Center and Pediatric Epilepsy Program at the Oregon Health & Science University, Portland.

Seizures are common in children, and about 10.5 million children worldwide have active, ongoing seizures. Every year in the United States, from 20,000 to 40,000 children with recurring, spontaneous seizures are diagnosed with epilepsy.

“Epilepsy is the most common treatable serious neurologic condition that occurs in childhood, and it’s the third most common neurologic condition that we diagnose and care for, following mental retardation and cerebral palsy,” Dr Roberts said.

“The onset of seizures is highest in the first year of life, and if that occurs, it puts children at significantly high risk of going on to continue to have seizures through their lifespan. The good news for pediatric epilepsy is that many children will outgrow these conditions and not go on to have them for the rest of their lives. Maybe 60 percent or more of children who are diagnosed with epilepsy in childhood will outgrow their seizures over time,” he said.

“It is clear that there are complex effects upon the life of a child and adult living with epilepsy. There can be underlying widespread cortical dysfunction. We also see the effects, unfortunately, of our therapies, which can be equally debilitating in many cases,” he commented.

Standard medical therapy consists of anticonvulsant medications.

“There has been a tremendous wealth of medications that have come on the market, and many of these are gaining pediatric applications,” he said. “The real benefits of the newer medications are that many of them have decreased systemic and cognitive behavioral toxicity compared to the older medications,” Dr Roberts said.

However, about one-third of pediatric epilepsy patients do not respond to anticonvulsant therapy.

“The response to the first medication given is the most important prognostic indicator. If you don’t respond to the first medicine, we begin to become worried that you won’t respond at all,” Dr Roberts added.

When medications fail to control the seizures, surgery may be considered.

“While we continue to consider large surgeries in some cases, our movement has been away from large surgeries toward the more focal-directed surgical approach,” Dr Roberts said.

“We have found that there are focal cortical abnormalities that are the basis of many intractable epilepsies, and if we can find that focus and successfully remove it, leaving other brain areas that are not involved in the epilepsy syndrome, we can not only succeed in controlling epilepsy but also improve outcomes,” he said.

Using magnetic resonance imaging, surgeons can identify an area of the brain involved in the epilepsy syndrome, create a small opening in the scalp, map the area electrically and then remove small amounts of tissue.

“Our goal is to take away as little as we can to do the most good,” Dr Roberts said.

“The pathology underlying many intractable epilepsy syndromes is the pathology termed broadly as cortical dysplasia,” he noted. Cortical dysplasia is a congenital abnormality characterized by abnormal migration of neurons in the brain near the cerebral cortex, causing signals sent through the neurons to misfire. It can have a genetic cause or be caused by insults to interuterine development during pregnancy.

If surgeons can identify the area of the brain with cortical dysplasia, they can remove it and significantly improve the symptoms of epilepsy and even cure the seizures in some cases.

Successful removal “depends largely on the identification of the lesion and the surrounding zone involved in the generation of the seizures,” Dr Roberts explained. “If the zone can be identified and removed completely, there is a significant rate of improvement.”

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Taking it to Extremes: New Sports are Dangerous

Video games have long featured Tony Hawk performing incredible stunts on a skateboard, which evolved into other daredevils performing jaw-dropping live stunts on television, which is evolving into more children and adolescents trying to duplicate those stunts around their homes.

Where does it all end? Often, it ends in an emergency room or the pediatrician’s office with an increasing number of head injuries, broken bones, damaged knees and battered bodies.

The variety of dangerous sports and the injuries they produce were discussed Sunday in the session “Extreme Young Athletes and Their Extreme Sports” by Andrew Gregory, MD, FAAP, FACSM, assistant professor of orthopedics and Pediatrics Program director, Vanderbilt University, who has also completed a sports medicine fellowship.

“What used to be extreme 10 to 20 years ago is not extreme now,” Dr Gregory said. “And it’s not just for boys any more, it is girls, too.”

Extreme sports started in the 1980s with skydiving, scuba diving, rock climbing, mountaineering, storm chasing, hang gliding and bungee jumping. Today, many of those “sports” are old hat and have been replaced by skateboarding, snowboarding, snowmobiling, dirt biking and BMX racing.

Just participating in these activities can be dangerous, but participants at all levels are increasingly pushing the envelope with acrobatic feats.

“The X Games is a TV term,” Dr Gregory said of competitions of the same name that draw millions of viewers on cable channels. “This drives a lot of extreme sports. It involves racing, doing tricks and a lot of jumping.”

This has expanded the territory of extreme sports to include surging, rally car racing, snowskating, wakeboarding, sport climbing, sky surging, street luge, ice climbing and super-modified shovel racing. Even disabled athletes are taking sports to the extreme in their own competitions.

As if this were not enough, Dr Gregory listed other new sports that he called “truly extreme,” base jumping, kayaking waterfalls, ultramarathons, ultimate fighting, super jumps, extreme adaptive rodeo, running with the bulls, cage diving with great whites and big wave surfing.

“Unfortunately this is all a little bit glorified,” he said, adding that one competitor lost his skateboard during a televised stunt and fell 40 feet, but walked away with only minor injuries. “Kids see this and think they can do it.”

Other competitions and television shows include the Gravity Games, the Dual Action Sports Tour, the Fuel TV network and MTV’s Scarred, which broadcasts videos of people being injured while performing stunts. You Tube on the Internet also features videos of stunts.

“This is something in the mainstream media now. Kids will watch this and emulate these things,” Dr Gregory said, adding that many professional performers have Web sites that glorify their injuries.

So what can pediatricians do about this growing danger to children? He recommended that pediatricians encourage the use of safety equipment and lessons to teach children skills needed in extreme sports before trying to perform them.

“First timers should take lessons,” Dr Gregory said. “You can get lessons at skate parks. Tell them ‘You can avoid a trip to my office if you wear wrist guards and a helmet.’”

He also said that younger children should start slowly by using scooters before moving on to skateboards. Studies show that injuries from these activities generate 50,000 emergency room visits a year, with many fractures of upper extremities, especially forearm fractures.

Dr Gregory reviewed the treatment options for some of these fractures and less severe injuries. Special splints have been shown to be as effective as casts for prevention of refractures while allowing better function. He also said pediatricians should consider giving patients their X-rays so they can be viewed in the future by other health care providers.

Children and adolescents often see protective equipment as uncool, so it helps to remind them that professionals usually wear helmets and wrist guards, he said.

“Here’s the extreme warning: Be careful with beginners,” Dr Gregory said. “Tell parents to give gift certificates for lessons and provide safety equipment along with presents.”

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New Definitions for Overweight, Obesity Recommended

An expert committee has lowered the definitions of obesity and overweight for children, and issued recommendations for physicians that will be released in a full report to be published in the December issue of Pediatrics.

Those definitions and recommendations were reviewed during Sunday’s Plenary Session by Nancy Krebs, MD, FAAP, a member of the expert committee. She said that the report introduces new terminology, medical assessments, patient-centered communication and four stages of obesity treatment. Preliminary recommendations from the committee report were released in June.

The expert committee was sponsored by the American Medical Association, the Department of Health and Human Services’ Health Resources and Services Administration, and the Centers for Disease Control and Prevention. It is supported by 15 other organizations, including the AAP, and changes definitions of overweight and obesity established in 1998.

Those 1998 definitions describe children in the 85-95 percentile range for their body mass index (BMI) age group as at-risk of being overweight and those above the 95th percentile as overweight. The new report calls those in the 85-95 percentile range overweight and those above the 95th percentile obese.

“This may be somewhat controversial, but I hope this will be an improvement,” Dr Krebs said of the new definitions. “The rationale for the terms was that the checkpoint minimized over- and under-diagnosis and there was a weaker correlation in children for BMI and body fat. There was a concern for the possible stigma for the terminology of obesity. The group struggled with this. It’s time to rethink definitions.”

The terms “at-risk of overweight” and “overweight” were misunderstood and misused by parents and providers, as well as in literature, and the new definitions also work better with adult BMI definitions of overweight and obesity, Dr Krebs said.

Because of the value placed on physical appearance, overweight children and their families often feel a stigma, which the committee addressed in recommendations for talking to families and patients.

“We recognized that stigmatization is still a legitimate concern. There will be specific recommendations in the summary report about potentially using different language when speaking with patients and families,” she said.

A new category of severe obesity for those with a BMI greater than the 99th percentile, which is strongly associated with co-morbidities that may need intervention, is also recommended, Dr Krebs said.

The report also assesses behaviors and attitudes for diet and physical activity. For diet, it recommends changes for the frequency of eating out, consumption of sweetened beverages and consumption of excessive portion sizes. For physical activity, the report recommends 60 minutes of moderate physical activity a day and less than two hours of sedentary behavior.

To prevent overweight and obesity, the report recommends BMI screenings for all children over age 2, a universal and consistent health message, patient-centered communication and early intervention.

The language is also important at these initial stages, and the report recommends that, when speaking to families, using language such as, “Your child’s height and weight put him at increased risk for developing diabetes and heart disease at a very early age,” Dr Krebs said.

Finally, the report recommends a staged approach for treatment:

• Stage 1: Prevention plus counseling on lifestyle behavior recommendations

• Stage 2: Structured weight management, including individual or group follow-ups, more frequent follow-ups, visits with a dietician or exercise therapist and self-monitoring

• Stage 3: Comprehensive, multidisciplinary actions, including increased intensity, a structured behavior program, diet and group sessions

• Stage 4: Tertiary care intervention, including a discussion of severe obesity, medications, very low-calorie diets and weight control surgery.

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