Wendy E. Mouradian

The differential diagnosis of posterior plagiocephaly : true lambdoid synostosis versus positional molding

&NA; The diagnosis and treatment of posterior plagiocephaly is one of the most controversial aspects of craniofacial surgery. The features of true lamibdoid synostosis versus those of deformational plagiocephaly secondary to positional molding are inadequately described in the literature and poorly understood. This has resulted in many infants in several craniofacial centers across the United States undergoing major intracranial procedures for nonsynostotic plagiocephaly. The purpose of this study was to describe the detailed clinical, imaging, and operative features of true lamhdoid svnostosis and contrast them with the features of positional plagiocephaly. During a 4‐year period from 1991 to 1994, 102 patients with posterior plagiocephaly were assessed in a large multidisciplinary craniofacial program. During the same period, 130 patients with craniosynostosis received surgical treatment. All patients were examined by a pediatric dysmorphologist, craniofacial surgeon, and pediatric neurosurgeon. Diagnostic imaging was performed where indicated. Patients diagnosed with lambdoid synostosis and severe and progressive positional molding underwent surgical correction using standard craniofacial techniques. Only 4 patients manifested the clinical, imaging, and operative features of unilambdoid synostosis, giving an incidence among all cases of craniosynostosis of 3.1 percent. Only 3 among the 98 patients with positional molding required surgical intervention. All the patients with unilambdoid synostosis had a thick ridge over the fused suture, identical to that found in other forms of craniosynostosis, with compensatory contralateral parietal and frontal bossing and an ipsilateral occipitomastoid bulge. The skull base had an ipsilateral inferior tilt, with a corresponding inferior and posterior displacement of the ipsilateral ear. These characteristics were completely opposite to the findings in the 98 patients who had positional molding with open lambdoid sutures and prove conclusively that true unilambdoid synostosis exists as a specific but rare entity. Awareness of the features of unilambdoid synostosis will allow more accurate diagnosis and appropriate treatment of posterior plagiocephaly in general and in particular will avoid unnecessary surgical intervention in patients with positional molding. (Plast. Reconstr. Surg. 98: 765, 1996.)

An oral health curriculum for medical students at the University of Washington.

Oral health disparities are a major public health problem, according to the U.S. Surgeon General. Physicians could help prevent oral disease, but lack the knowledge to do so. To create an oral health curriculum for medical students at the University of Washington School of Medicine, the authors (beginning in 2003) (1) reviewed current evidence of medical education and physician training in oral health, (2) developed oral health learning objectives and competencies appropriate for medical students, and (3) identified current oral health content in the undergraduate curriculum and opportunities for including additional material. The authors identified very few Medline articles on medical student education and training in oral health. The United States Medical Licensing Examination Steps 2 and 3 require specific clinical knowledge and skills in oral and dental disorders, but other national curriculum databases and the Web site of the Liaison Committee on Medical Education devote no significant attention to oral health. To develop learning objectives, the authors reviewed major oral health reports, online oral health educational resources, and consulted with dental faculty. The curriculum was assessed by interviewing key medical school faculty and analyzing course descriptions, and was found to be deficient in oral health content. The authors developed five learning themes: dental public health, caries, periodontal disease, oral cancer, and oral–systemic interactions, and recommend the inclusion of corresponding competencies in targeted courses through a spiral curriculum. Current progress, the timeline for curriculum changes at the University of Washington, and the ethical values and attitudinal shifts needed to support this effort are discussed.

The Differential Diagnosis of Abnormal Head Shapes: Separating Craniosynostosis from Positional Deformities and Normal Variants

The correct differential diagnosis of an abnormal head shape in an infant or a child is vital to the management of this common condition. Establishing the presence of craniosynostosis, which warrants surgical correction, versus non-synostotic causes of head deformity, which do not, is not always straightforward. This paper deals with three groups of abnormal head shape that may cause diagnostic confusion: the spectrum of metopic synostosis; the dolichocephaly of prematurity versus sagittal synostosis; and the differential diagnosis of plagiocephaly. Special emphasis has been placed on the problem of posterior plagiocephaly, in the light of recent evidence demonstrating that lambdoid synostosis has been overdiagnosed. Metopic synostosis presents as a wide spectrum of severity. Although only severe forms of the disorder are corrected surgically, all cases should be monitored for evidence of developmental problems. The dolichocephalic head shape of preterm infants is non-synostotic in origin and is managed nonsurgically. The scaphocephalic head shape resulting from sagittal synostosis requires surgical intervention for correction. Posterior plagiocephaly may be due to unilambdoid synostosis or positional molding, which have very different clinical and imaging features. True lambdoid synostosis is rare. Most cases of posterior plagiocephaly are due to positional molding, which can usually be managed nonsurgically. Regardless of the suture(s) involved, all children with confirmed craniosynostosis should be monitored for increased intracranial pressure and developmental problems.

Presurgical and postsurgical mental and psychomotor development of infants with sagittal synostosis.

OBJECTIVE The current study compared the mental and psychomotor development of infants with nonsyndromic sagittal synostosis (SS) with a demographically matched comparison group without congenital defects. Within the SS group, we tested the hypothesis that age of cranial release would be inversely correlated with mental development. DESIGN The design was prospective and longitudinal. Participants were assessed at 4, 12, and 24 months of age. SETTING The study was conducted in a craniofacial clinic at an urban childrens hospital. PARTICIPANTS Participants were 19 infants with SS (consecutive craniofacial program referrals) and 19 demographically matched comparison infants recruited from the community. One infant with SS did not attend the 24-month assessment. MAIN OUTCOME MEASURES Mental and Psychomotor Indices from the Bayley Scales of Infant Development were the primary outcome measures. Subdomains of development were created using Kohen-Raz scoring procedures. All measures were determined a priori. RESULTS Repeated-measures MANOVAs revealed no statistically significant differences in the developmental trajectories of the two groups. None of the SS group infants received Mental Development Index (MDI) scores in the mentally retarded or borderline range of intellectual functioning (i.e., below 78). An inverse correlation (r = -.30) was found between the age at surgery and Bayley growth curve coefficients; however, this association was not statistically significant (p = .10, one-tailed). CONCLUSIONS Results are consistent with previous studies of the mental and psychomotor development of infants with nonsyndromic craniosynostoses in relation to normative test data. The relation between surgery age and developmental outcome merits further study in a larger sample with a greater range of surgery ages.

Preventive dental care for children in the United States: a national perspective.

OBJECTIVE. Preventive dental care is a cornerstone of optimal oral health. However, in 1996, only 38% of US children received preventive dental care. We used the National Survey of Childrens Health to (1) describe the proportion of US children with ≥1 preventive dental visit within the previous year, (2) identify factors that were associated with preventive dental care use, and (3) test the hypothesis that preventive dental care use by near-poor children is associated with State Child Health Insurance Program policies for covering dental care. METHODS. The National Survey of Childrens Health includes data from 102353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was ≥1 preventive dental visit in the past year. We conducted multivariate regression analysis to identify factors that were associated significantly with this outcome using Stata survey capabilities. RESULTS. In 2003, 72% of US children had a reported preventive dental care visit in the previous year. On multivariable analysis, we found that being young, black or multiracial relative to white, lower income, and lacking a personal doctor were variables with a significantly lower likelihood of a preventive dental visit. Children in states with State Child Health Insurance Program dental coverage and broadest income eligibility had a 24% higher likelihood of a preventive dental visit when compared with children in states with limited or no State Child Health Insurance Program coverage for dental services, on adjusted analysis. CONCLUSIONS. Although the proportion of US children with a preventive dental visit now is higher than previously reported, children who are at highest risk for dental problems still are those who are least likely to receive preventive dental care. When states cover preventive dental care at income eligibility levels ≥200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

Approaches to Craniofacial-Specific Quality of Life Assessment in Adolescents

Objective To ascertain the domains that adolescents aged 11 to 18 years with congenital and acquired craniofacial differences (CFDs) consider important to their quality of life (QoL) to create a craniofacial-specific module. Design Interviews and inductive qualitative methods were used to guide the development of a conceptual and measurement model of QoL among adolescents with CFDs. Setting The Craniofacial Center at Childrens Hospital and Regional Medical Center in Seattle, Washington. Patients, Participants Thirty-three in-depth interviews with adolescents (aged 11 to 18 years), one young adult interview (age 19 years), 14 in-depth interviews with parents, one young adult focus group, one parent focus group, and one panel of researchers and clinical professionals working in the field. Results Using the qualitative methodology, grounded theory, seven domains that adolescents with CFDs perceive are important to having a good QoL were found. Six of the domains (coping, stigma and isolation, intimacy and trust, positive consequences, self-image, and negative emotions) comprised the Youth Quality of Life Instrument–Facial Differences module. One other domain, surgery, was a salient issue for many of the youth, but not all, so it was made into a separate module, the Youth Quality of Life Instrument– Craniofacial Surgery module. This module relates to the experience of surgery, outcomes of surgery, and preferences for future surgery. Conclusions Using an established qualitative methodology, two QoL modules specific to adolescents with CFDs were developed and are ready for psychometric validation. Potential uses of the instruments are discussed.

A New Oral Health Elective for Medical Students at the University of Washington

Background: Oral health is an important but inadequately addressed area in medical school curricula. Primary care practitioners are in an ideal position to help prevent oral disease but lack the knowledge to do so. Purposes: We developed an oral health elective that targeted 1st- and 2nd-year medical students as part of a previously described oral health initiative and oral health curriculum. Methods: To promote interprofessional collaboration, we utilized medical–dental faculty teams for lectures and hands-on peer instruction by dental students for clinical skills. Results: Evaluations revealed positive shifts in attitudes toward oral health and significant gains in oral health knowledge and self-confidence. Students rated the course highly and advocated for further integration of oral health into required medical curricula. Conclusions: We describe the elective including curriculum development, course evaluation results, and steps for implementing a successful oral health elective into medical education. We highlight interprofessional collaboration and constituency building among medical and dental faculty and administrators.

Maintaining and Improving the Oral Health of Young Children

Oral health is an integral part of the overall health of children. Dental caries is a common and chronic disease process with significant short- and long-term consequences. The prevalence of dental caries for the youngest of children has not decreased over the past decade, despite improvements for older children. As health care professionals responsible for the overall health of children, pediatricians frequently confront morbidity associated with dental caries. Because the youngest children visit the pediatrician more often than they visit the dentist, it is important that pediatricians be knowledgeable about the disease process of dental caries, prevention of the disease, and interventions available to the pediatrician and the family to maintain and restore health.

Future Directions in Leadership Training of MCH Professionals: Cross-Cutting MCH Leadership Competencies

Leadership in Maternal and Child Health (MCH) requires a repertoire of skills that transcend clinical or academic disciplines. This is especially true today as leaders in academic, government and private settings alike must respond to a rapidly changing health environment. To better prepare future MCH leaders we offer a framework of MCH leadership competencies based on the results of a conference held in Seattle in 2004, MCH Working Conference: The Future of Maternal and Child Health Leadership Training. The purpose of the conference was to articulate cross-cutting leadership skills, identify training experiences that foster leadership, and suggest methods to assess leadership training. Following on the work of the Seattle Conference, we sub-divide the 12 cross-cutting leadership competencies into 4 “core” and 8 “applied” competencies, and discuss this distinction. In addition we propose a competency in the knowledge of the history and context of MCH programs in the U.S. We also summarize the conference planning process, agenda, and work group assignments leading to these results. Based on this leadership competency framework we offer a definition of an MCH leader, and recommendations for leadership training, assessment, and faculty development. Taken as a set, these MCH leadership competencies point towards the newly-emerging construct of capability, the ability to adapt to new circumstances and generate new knowledge. “Capstone” projects can provide for both practice and assessment of leadership competencies. The competency-based approach to leadership that has emerged from this process has broad relevance for health, education, and social service sectors beyond the MCH context.

Making decisions for children.

Making decisions for children is part of everyday orthodontic care. When conflicts arise between providers and parents, articulation of the ethical and legal principles guiding the process can be helpful. Parents are generally decision makers for their minor children, a presumption supported for practical and moral reasons and by legal precedent. The best interests of the child must guide both parents and providers. As the child matures, he or she should be brought into the decision making process as age and ability allow. A childs competency is a function of age, cognitive abilities, and personal experiences. The child should participate in the decision making process to facilitate trust, cooperation, and the development of future decisional capacities. The concepts of informed consent, parental permission, and child assent are compared and contrasted. Tables are provide that summarize these concepts and offer guidelines for providers working with children.