The Medical History: Easy ways to approach and an uneasy task

Every hospital and clinic in the world has a form which requires the recording of the patent's medical history. While no one doubts the importance of this step, it is not the most pleasant of tasks. In children where parents are either unaware or unwilling to share medical history this step is often even more unpleasant. Many a practitioner gives the excuse of a "busy schedule" to avoid having to take this history. Fortunately, or rather unfortunately, the likelihood of encountering a child with a serious medical problem or drug allergy is rare thereby making the the chance of a complication rare. But the question is do we really want to take that chance?

Rule 1: Don't be afraid to ask -  Very often parents are not ashamed to answer questions regarding their child's medical health, especially when they are aware of the risk involved in treatment. They may be more defensive about questions regarding mental health, but here again the right phraseology can make all the difference. The difference between "does your child have a mental problem?" and "how is your child coping with school?" can be the difference between your obtaining a history or not.

Rule 2: Take the history yourself -  Many clinics and hospitals rely on forms filled out by parents or let the history be taken by the dental assistant, checking the recorded facts only takes a few minutes, but surprisingly you will find that they either forgot to mention something or they reinforced something that you almost missed when you read the history the first time.

Rule 3: Do not guess the medication the child is on -  while it may be easy to assume that the child was given an antibiotic and analgesic for pain medications for other diseases are a lot harder to guess. Even if you are sure about the drug of choice or the most frequently prescribed medication it doesn't hurt to look at the prescription. If the child is suffering from a serious problem, such as a cardiac condition the parents will often carry the prescription with them, if however the medication was stopped, as it often is in cases of childhood epilepsy or asthma, parents do not remember when exactly the ,medications were stopped or what exactly was the drug given. Here the last prescription can be a useful tool to your diagnosis.

Rule 4: If the child is on medication make sure the medication is readily available -  If the child is currently on medication it is essential to confirm that the medication was taken before the visit. In cases of asthma, do not start treatment unless the inhaler is available. When it comes to antibiotic prophylaxis it is better to administer the prophylaxis yourself. The prophylactic dose for a 20 Kg child is 1000mg, which is 20 ml of syrup. Most patients find this much syrup unpleasant, and almost all parents will be convinced that you are overdosing their child with antibiotics.

Rule 5: Tell the parents to call their pediatrician to confirm your treatment plan - Regardless of your expertise and specialization, many parents are more comfortable with the opinion of the "doctor" over that of the "dentist". Just the fact that you are confident enough to have your diagnosis "tested" by the pediatrician can be very reassuring for the parent. 

Rule 6: When in doubt : REFER -  Heroic and noble as the field of special care dentistry is, it is not a substitute for the opinion of a physician or a pediatrician. If you are in doubt as to the suitability of dental treatment - refer the child for a medical opinion.

A diet to control autism? Welcome to the GFCF diet

The autism spectrum disorders (Childhood autism, Aspergers Disease and Rett's syndrome) can take a huge toll on the caregiver and dentist alike. The energy and time spent in deling with a child with special health care needs can drain even the most patient of us. It is therefore the dream of every parent of an autistic child to be able to find a cure that will calm the child down, and the Gluetein free Casein free diet (GFCF) diet is supposed to do just that.

Historical Background

In the 1960s, Curtis Dohan speculated that the low incidence of schizophrenia in certain South Pacific Island societies was a result of a diet low in wheat and milk-based foods. Dohan proposed a genetic defect wherein individuals are incapable of completely metabolizing gluten andcasein as a possible etiology for schizophrenia. Dohan hypothesized that elevated peptide levels from this incomplete metabolism could be responsible for schizophrenic behaviors.

The possibility of a relationship between autism and the consumption of gluten and casein was first articulated by Kalle Reichelt in 1991.Based on studies showing correlation between autism and increased urinary peptide levels, Reichelt hypothesized that some of these peptides may have an opiate effect. This led to the development of the Opioid Excess Theory, expounded by Paul Shattock and others,which speculates that peptides with opioid activity cross into the bloodstream from the lumen of the intestine, and then into the brain. These peptides were speculated to arise from incomplete digestion of certain foods, in particular gluten from wheat and certain other cereals and from casein from milk and dairy produce. Further work confirmed opioid peptides such as casomorphines (from casein) and gluten exorphines andgliadorphin (from gluten) as possible suspects, due to their chemical similarity to opiates. Reichelt hypothesized that long term exposure to these opiate peptides may have effects on brain maturation and contribute to social awkwardness and isolation. On this basis, Reichelt and others have proposed a gluten-free casein-free (GFCF) diet for sufferers of autism to minimize the buildup of opiate .

Does it Work?

The opinion of the medical world is certainly divided on this issue. While several parents and institutions swear by the efficacy of the GFCF diet, many doctors have remained skeptical of it's efficacy. Research on the diet has been sketchy at best and there are no randomized control trials showing its efficacy. On the contrary it has been argued that the nature of children with autism makes any form of Randomized control difficult if not impossible, and that the positive reactions of thousands of parents cannot be dismissed lightly.

Is it safe?

Whether the diet works or not the far more imporntant issue is one of safety. The only way to implement the GFCF diet is to restrict the intake of milk and milk products in order to eliminate casien (which is a milk protein). Children with Autism have been known to have weaker bones and autistic children who were on GFCF diets have been shown to have significantly lower cortical bone thickness than autistic children who were not. Advocates of the diet aknowledge this fact but attribute it to the fact that a GFCF diet without alternate sources of protein is the problem and not the diet itself.

Implementation of the diet

As mentioned above the GFCF diet involves complete elimination of all sources of glutein such as wheat, rye and barley. The elimination of casien includes the elimination of milk and milk products such as cheese. Whey or curd, however, is said to be acceptable. The traditional Indian food of Curd Rice is therefore a perfect example of GFCF food. Extensive information regarding GFCF diets and their iplementation can be found at www.gfcfdiet.com/

In conclusion

DCSN recognizes the importance of reducing the levels of opiod peptides in autistic children, and acknowledges the ability of the GFCF diet in doing so. But the consquence of removing casien and glutein from the child's diet must be kept in mind and suitable alternatives must be given after discussion with the dietician and/ or the pediatrician.

Intellectual disability: New name for an old problem???

It is never easy for any one to deal with a child with mental retardation. It is hard for the child no doubt, but equally hard for the parent to come to terms with the fact, and harder still for the dentist to approach the subject with the parent. 

A blunt " Is your child normal?" is not only insulting to the parent and child alike but also; given the broad range of the term "normal" thoroughly unprofessional. 

One of the ways in which the profession has tried to circumvent this problem has been to come up with newer and more "socially correct" terms. But does this really help us understand the condition or does it simply complicate matters by presenting us with a confusing array of terms which mean little to most? In this series of posts DCSN takes a look at our understanding of intelligence, intellect and the various conditions which manifest with intellectual disability.

Definition

The evolution of the term

Intelligence and measuring intelligence

Conditions which manifest with intellectual disabilty

Intellectual disability: The Evolution of the term

As late as the an first two decades of this century people with mental disorders were routinely referred to by terms that would seem shocking today; the picture above is taken from a leading book on ,mental health in children published in 1913. Fortunately today such degrading terms are no longer acceptable to society. However we remain in just as much confusion over how to address the person with intellectual disability. Over the years different authors and associations have tried to define a set of terms. Here we look at those terms and the rationale for adopting the term intellectual disability.

The story of how we treat individuals with intellectual disability can be traced by studying the evolution of the institutions we have set up to treat, study and better the lives of individuals with intellectual disability. From the punitive ,methods of the 19th century where people were branded as lunatics and chained, to the 21st century we have indeed come a long way. One of the organizations that has played an important and certainly influential role in how we perceive impaired intellect has been the American association on intellectual and developmental disabilities (AAIDR) previously called the American Association on Mental Retardation (AAMR).

Founded in 1876, AAIDD is the world's oldest and largest interdisciplinary organization of professionals concerned about mental retardation and related developmental disabilities. With headquarters in Washington, DC, AAIDD has a constituency of more than 50,000 people and an active core membership of over 3,500 in the United States and in 55 other countries. The mission of AAIDD is to promote progressive policies, sound research, effective practices, and universal rights for people with intellectual disabilities.

AAIDD has updated the definition of mental retardation ten times since 1908, based on new information, changes in clinical practice, or breakthroughs in scientific research. The 10th edition of Mental Retardation: Definition, Classification, and Systems of Supports (2002) contains a comprehensive update to the landmark 1992 definition and provides important new information, tools, and strategies for the field and for anyone concerned about people with intellectual disability.AAIDD anticipates publishing the next classification manual in 2010/2011.

Intellectual disability is the currently preferred term for the disability historically referred to as mental retardation. Although the preferred name is intellectual disability, the authoritative definition and assumptions promulgated by the American Association on Intellectual and Developmental Disabilities (AAIDD and previously, AAMR) remain the same as those found in the Mental Retardation: Definition, Classification and Systems of Supports manual 

What is Intellectual disability?

Intellectual disability is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before the age of 18.

The term intellectual disability covers the same population of individuals who were diagnosed previously with mental retardation in number, kind, level, type, and duration of the disability and the need of people with this disability for individualized services and supports. Furthermore, every individual who is or was eligible for a diagnosis of mental retardation is eligible for a diagnosis of intellectual disability.

What causes intellectual disability?

Intellectual Disability or mental retardation is an umbrella term which is seen in a wide variety of conditions. Strictly speaking the clinician should treat intellectual disability as clinical sign suggestive of an underlying pathology rather than as a disease in itself. Given below is a list of conditions that can lead to intellectual disability

Causes of intellectual disability

(from Bherman Et al (ed) Nelson's Textbook of Pediatrics)

Category	Type	Examples
Prenatal (causes before birth)	Chromosomal disorders	Downs syndrome*, Fragile X syndrome, Prader Wili syndrome, Klinefelters syndrome
	Single gene disorders	Inborn errors of metabolism, such asgalactosemia*, phenylketonuria*,mucopolysaccaridoses Hypothyroidism*, Tay- Sachs disease        Neuro-cutaneous syndromes such as tuberous     sclerosis, andneurofibromatosis Brain malformations such as geneticmicrocephaly, hydrocephalus and  myelo-meningocele* Other dysmorphic syndromes, such as Laurence  Moon Biedl syndrome
	Other conditions of genetic origin	Rubistein Tabi syndrome De Lange syndrome
	Adverse material / environmental influences	Deficiencies* , such as iodine deficiency and folic acid deficiency Severe malnutrition* in pregnancy Using substances * such as alcohol (maternal alcohol syndrome), nicotine, and cocaine during early pregnancy Exposure* to other harmful chemicals such as  pollutants, heavy metals,abortifacients, and harmful medications such as thalidomide,phenytoin and warfarin sodium in early pregnancy Maternal infections such as rubella*,syphillis*,    toxoplasmosis,cytomegalovirus and HIV       Others such as excessive exposure to radiation*, and Rh incompatibility*
Perinatal  (around the time of birth)	Third trimester ( late pregnancy)	Complications of pregnancy* Diseases* in mother such as heart and kidney  disease and diabetes Placental dysfunction
	Labour (during delivery)	Severe prematurity, very low birth weight, birth  asphyxia Difficult and/or complicated delivery*  Birth trauma*
	Neonatal (first four weeks of life)	Septicemia, severe jaundice*, hypoglycemia
Postnatal  (in infancy and childhood)		Brain infections such as tuberculosis, Japanese  encephalitis, and bacterial meningitis Head injury* Chronic lead exposure* Severe and prolonged malnutrition* Gross understimulation*

Intelligence Testing - IQ and the feasabilty of IQ testing

 Sir Francis Galton   Alfred Binet

The science of testing an individual's intelligence has always been one mired in controversy. From questions about the accuracy of these tests to questions about their ethics; the task of evluating intelligence has always been treated with some measure of skepticism.The history of IQ began in the ninetheenth century with sir Francis Galton. He was a british scientist known as a dabbler in many different fields, including biology and early forms of psychology. After the shake-up from the 1859 publishing of Charles Darwin's "The Origin of Species", Galton spent the majority of his time trying to discover the relationship between heredity and human ability. He believed that mental traits are based on physical factors.

    Galton's ideas on intelligence were influenced also by the work of a Belgian statistician named Lambert Adolphe Jacques Quetelet. Quetelet was the first to apply statistical methods to the study of human characteristics, and actually discovered the concept of normal distribution. However Galton's irrational belief in races with "superior" intellect led to the development of biased and often blatantly unfair tests.

                 It was a Frenchman named Alfred Binet who in 1904 developed the first objective 

intelligence test. Commissioned by the French government to come up with a test to differentiate between children who had an inferior intellect and those who were normal.Binet's test simply put evaluated the average tasks that should be performed by a child of a given age to obtain mental age. This was then divided by the chronological age and multiplied by 100 to get the IQ. This simple formula to date remains the backbone of intelligence testing. Binet's work was brought to America and modified at Stanford University  by Lewis M. Terman , and thus the famous "Stanford-Binet" intellegence test was born. The fourth edition of this test the SB-IV is still widely used.

Left:The orignal Binet test

Obviously the IQ test would require the child to read the questions or at least have the questions read to him/her. A large number of children who have never been to school or who are illiterate  therefore cannot be evaluated by the Binet tests. In order to overcome this difficulty the Wechsler Intelligence tests were developed. The Wechsler Intelligence Scale for Children (WISC), developed by David Wechsler, is an intelligence test for children between the ages of 6 and 16 inclusive that can be completed without reading or writing.The WISC was originally developed as a downward extension of the Wechsler Adult Intelligence Scale in 1949. A revised edition (WISC-R) in 1974 as the WISC-R, and the third edition, the WISC-III in 1991. The current version, the WISC-IV, was produced in 2003.

 While there is no doubt that the testing of IQ can help detect early signs of intellectual disability their accuracy in judging how smart a child is remains questionable. The tests also have an element of bias. All tests retain an element of cultural knowledge. An Indian child may not know what a snowman is or what blueberry pie tastes like, not because he/she is dull, but for the obvious reason that he/she has very little chance of having seen either. It is for this reason that several IQ tests have been developed specifically keeping in mind the Indian population.

The Standford-Binet test has been adapted for an Indian population by Kamath in 1940 and is known as the Binet-Kamath Test. One of the critisisms of this test however has been that the test provides tasks that are too easy and therefore do not accurately measure IQ. The Bhatia IQ test is another widely used IQ test for Indian children Most intelligence tests are designed to provide an I.Q. (intelligence quotient) score. The mental age is based on a set of norms that have been devised by collecting data on a fairly large sample of children of different ages, whom the test makers believe are representative of a population at large.

 One of the criticisms of I.Q. tests is that most tests are not truly representative, especially regarding lower income and minotiry groups. Even if I.Q. tests are truly representative, they have some drawbacks. Foremost, traditional psychometric tests of intelligence are based on the proposition that human beings are endowed with a single, "general faculty" for acquiring information. Secondly, as a person is given a fixed I.Q. score, his/her intelligence is taken to be a fixed, unchanging entity. Traditional tests of intelligence do not take situational and contextual information into account. Thirdly, they penalise a child for a creative or unconventional answer.

In conclusion we can say that the testing of intelligence is only a tool for the diagnosis of intellectual disability. Using these tests to evaluate the brilliance of the child is not only unfair, but also most probably inaccurate.

Antibiotic Prohylaxis : Does it Work

Over the past year there has been a flood of information disputing the effectiveness of antibiotic prophylaxis. Ever since the American Heart revised it's prophylactic regimen in 2007, every dental association has been quick to critisize the concept of prophylaxis. Ironically the criticism has been as vehment as the endorsements a few years back.

How much have things really changed? What do the findings mean for us clinically? IS prophylaxis no longer needed? DCSN looks at the long history of antibiotic prophylaxis regimen and the implications of the current regimen for special care dentistry.

• History
  
• Rationale
  
• Changes made and the reasons for those changes
• Clinical Implications
  

History of the anitbiotic prophylaxis regimen

The history of antibiotic prophylaxis is one of substantial ignorance and profound abuse.Although the rationale for infective endocarditis prophylaxis has been understood since the 1950's the application of this theory into practice has undergone many changes. The AHA has made recommendations for the prevention of IE for more than 50 years. 

from Wilson W et.al Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

J Am Dent Assoc 2007 138: 739-760

Between 1955 and 1997 the AHA guidelines were modified 8 times, each modification making allowance for previously unexplained phenomenon such as penicillin resistance, or the shift to safer drugs such as erythromycin and later clindamycin from more dangerous drugs such as chloramphenicol for penicillin allergic patients.The 1997 document stratified cardiac conditions into high-, moderate- and low-risk (negligible risk) categories with prophylaxis not recommended for the low-risk group. An even more detailed list of dental, respiratory, GI and GU tract procedures for which prophylaxis was and was not recommended was provided. The 1997 document was notable for its acknowledgment that most cases of IE are not attributable to an invasive procedure but rather are the result of randomly occurring bacteremias from routine daily activities and for acknowledging possible IE prophylaxis failures.

However despite this knowledge,it would take another 10 years before the AHA would put this knowledge into practice. The 2007 guidelines and their acceptance by the ADA in 2008, place a great emphasis on the role of transient bacteremia due to daily activities and greatly reduce the number of conditions where prophylaxis is required. This however DOES NOT mean that prophylaxis is not necessary or that the concept is redundant.

Rationale of antibiotic prophylaxis in dentistry

The development of IE is the net result of the complex interaction between the bloodstream pathogen with matrix molecules and platelets at sites of endocardial cell damage. In addition, many of the clinical manifestations of IE emanate from the host’s immune response to the infecting microorganism. The following sequence of events is thought to result in IE: formation of nonbacterial thrombotic endocarditis (NBTE) on the surface of a cardiac valve or elsewhere that endothelial damage occurs, bacteremia, adherence of the bacteria in the bloodstream to NBTE and proliferation of bacteria within a vegetation.

Formation of NBTE. Turbulent blood flow produced by certain types of congenital or acquired heart disease, such as flow from a high-to a low-pressure chamber or across a narrowed orifice, traumatizes the endothelium. This creates a predisposition for deposition of platelets and fibrin on the surface of the endothelium, which results in NBTE. Invasion of the bloodstream with a microbial species that has the pathogenic potential to colonize this site can then result in IE.

The conventional arguement has therefore been that any dental procedure would result in a transient bacteremia that would then trigger the formation of a vegetative thrombus in an individual who had a succeptible endothelium. Thus all invasive dental procedures carried out in succeptible individuals would require a prophylactic antibiotic regimen to avoid transient bacteremia.

The case against Prohylaxis

The primary case against prophylaxis has been one of effectiveness. It has been pointed out that no antibiotic can guarentee complete freedom from bacteremia and furthermore the chances of bacteremia from daily activities is far greater than many dental procedures

from Pallasch et al 2005 

The findings shown above greatly questioned the traditional view of the AHA, in 1997 the AHA for the first time admitted that the chances of bacteremia from daily oral hygiene procedures was as high as that of certain dental procedures. Keeping this in mind the AHA in 2007 revised their prophylactic regimen for dental procedures.

This however does not mean that prophylaxis is not required. It only reduced the individuals who required prophylaxis and eliminated a few procedures for which prophylaxis was required.

The reasons for change and changes made