Wren's Teeth

This morning Wren had his first crown.  It is silver and he is quite proud of it.  Joshua said "you are now a cyborg because you have a metal tooth"

While we were scooting Wren asked:  "Mom, is my tooth made of metal?"

I replied that it was made of surgical steel.

"It IS made of metal Dad!" he said gleefully. 

"I have a metal tooth!"

Enthusiasm aside, Wren is just five years old so its very unfortunate that it came to this and you are probably thinking is this dentist on crack?

She is not.  She is a really most excellent and kind dentist.  When we first started attending her practice five years ago we could only get an appointment for preschoolers because she was so highly regarded and fully booked during school hours.  Years later we have caused her to come in twice on holidays to deal with Wren's dental issues.  So, she is nice and skilled but we are rather weary of seeing even the most lovely dentist.

So, how did we come to this?

Kids with heart defects have to be careful with dental care and hygiene.  You may have heard the urban myth about human bites being the most infectious?  It is most likely untrue but while being less toxic than a dog's bite, a human mouth has plenty of thriving bacteria.   People with various heart conditions are at higher risk of getting bacterial endocarditis from bacteria in the bloodstream, released during dental procedures.   As a result, Wren's must get more aggressive dental treatment and take amoxicillan at every appointment.  Yes, I know that's an antibiotic by the way. 

Because we live in the progressively anti-antibiotic environment of naturopathic Seattle, I am going to give you the longer answer about dental care so you don't blanch when I mention Wren has had antibiotics 8 or 9 times in the past 4 months, that's with every filling.  But wait, I am getting ahead of myself.

"Certain heart conditions and structural defects increase the risk of developing endocarditis (heart valve infection) following dental procedures. Bacterial Endocarditis means infection in the heart, specifically the heart valves (bacteria = germs; endo = inside; carditis = heart inflammation). It occurs when bacteria spread through the bloodstream and land inside the heart and grow there. Usually, if there are bacteria circulating in the bloodstream, they don't stick to the inside of the heart: the blood flows smoothly. If the heart is abnormal due to certain types of surgery or other defects, there may be rough surfaces causing turbulent blood flow (known as a murmur) to which bacteria can attach and cause infection. Antibiotics are used to try to prevent this dangerous infection in some cases. The decision whether to take antibiotics depends on two major factors: first, is the procedure likely to cause a significant number of bacteria to enter the bloodstream; and second, is the heart particularly subject to infection."

Source:  ParentHeartWatch

Wren required 5 fillings when he had his first dentist visit.  We don't know why he had so many cavities.  He and Frost eat a similar diet but Frost has had only one filling by age 10.  These things are sent to try us, I suspect.

Unfortunately, for reasons not fully understood, some of Wren's fillings in the lower molars keep falling out, cracking and coming loose.  Since October, we have been to the dentist for a cavity replacement every second week - for one of two fillings.  Finally, when the right cavity fell out for (what feels like and may well be) the 5th time, we decided to try something else.  Wren has been doing very well with the new fillings, the doctor does them quickly with a dental dam or cotton rolls, but he grinds his teeth at night and for that or some other reason, they are not remaining in.

The new plan is to crown all the teeth that have recurrent filling loss.

Today, for the first crown, it took about an hour for the whole appointment and the worst part was getting on the "tooth raincoat" or dental dam to keep the tooth dry.  Wren has a strong gag reflex and so dental work causes him to panic when his open mouth causes him to retch.  Coupled with some drama and discomfit from the analgesic shot, he was very sad and stricken.

Sadly, a third filling which had not been replaced to date had looked odd to me the night before.  I asked the dentist to look at that too and she said it has also cracked.  She gave me the option of a crown next week or another temporary, done today.  I picked the temporary as it may give us a few weeks of wear and allow Wren to do some forgetting of the trauma before the next crown.  One down, two to go.

He watched two episodes of MAD TV on the iPad and I had a core workout to balance on the dentist's chair and hold the iPad above him while not getting in the way of the dentist and her assistant.   At the end of it, Wren was sad and needed a smoothy so Josh went to Whole Foods for one.

Peanut Butter Moo'd and Minecraft helped during the recovery and he is now a happy cyborg.  Till next time.

Synagis or No Synagis?

I drove through the remains of last night's snow to take both boys to the pediatrician today. Frost had a plantar wart frozen off and Wren had his 2 year check-up. Wren is doing well in all the Normal Baby things. He is developing normally in all areas and was ahead of the curve in his ability to jump up and down on the spot. He also understood all the pediatrician's instructions to "lie on your back", "roll over" and "take big deep breaths now" which pleased her a great deal.

Stats:

• 36.5 inches long = 90th percentile
• 27 lbs 9 oz = 45th %tile
• 19 7/8 " head circumference = 85th %ile
• hematocrit normal (11.8 up from 11.3 pre-surgery)

Here is Frost having his wart frozen while he squeezes Wren's raccoon.

Shots
On the way to the pediatricians Frost was begging to have a shot himself. He said that if he could have a shot he could show Wren it was OK and how to do it. I was a bit taken aback by this but when we came into the doctor's room he asked again. She checked the chart and found he did need a shot - his Hep A booster and Hep B (one of those I refused early on).

Frost had his shots first and managed not to cry, just to say "ow" rather plaintively while sucking vigorously on a candy-cane I gave him as an incentive during the nitrogen-freezing of the wart.

Wren received Hep A & B and varicella (another I had refused for Frost until Wren's CHD). Wren was very sad afterwards and said "go home, all done, get dressed" in one breath. Thankfully it was all done.

The Synagis Question
On our cardiologist's recommendation (Dr Olson) we had asked our pediatrician to order Synagis this year. Apparently the recent surgery and the ongoing haemodynamic disturbance meant that Dr Olson feels "he could get pretty sick" if he contracted RSV. Synagis is made from immunoglobin and each shot (for a 2 year old) costs around $4,000. He would need 4 doses this year.

This is the status of the application:
1) December - applied for insurance coverage for Synagis.
2) Cover REFUSED (December 10th)
3) Appeal placed by pediatrician (on my request). Cardiologist submitted requested evidence.
4) Insurance said approval on appeal UNLIKELY. Ped notified cardiology about refusal and asked "how far to push the appeal."
5) Card responded that since he is now 2, we need not push all the way.
6) Discussed with us and we decided no Synagis - Wren would be OK without it. Ped suggested we avoid big crowds of children and regular LARGE playgroups to reduce risk of RSV and respiratory problems.
6) Today, insurance faxed APPROVAL for 4 months of Synagis. Ped very surprised.
7) Ped notified Card about what to do. He said emailed "good. He should get it "he could get pretty sick if he gets RSV."
8) Ped notifies us and asks what we want to do.

So, my question is "Shall we order Synagis for Wren?" Its been approved but he may not need it. He IS 2. It is painful. It is very expensive [for insurance]. I shall have a talk with Joshua and make a decision. I think our insurance will cover home-help doing it (which means they send a nurse to give him the shot at home rather than visiting a clinic) which is much less stressful for all of us.

Socialization
Apparently the one area our pediatrician would like us to do something is in Wren's social life. She noticed that he is very social and wants to make sure he has some interaction with peers (other toddlers). He tends to run around with nerf guns and knows Indiana Jones, Transformers and Batman so she is probably right in asking if he has babies to stack blocks with. She suggested we set up a small playgroup at home rather than join a preschool playgroup to avoid the germiness of big playrooms. I shall see what I can figure out. Any toddlers want to play with Wren? He plays well and we can put away the shark guns.

Dentist
We have also been asked to set up a first dentist visit for the next 6 months. I have an amoxicillan prescription for a prophylactic in case of a tooth cleaning. Its to avoid endocarditis. Apparently early cleanings are a good idea to reduce build up of the kind of bacteria which can cause heart infection later on.

PS.
Here is the snow last night!