Injuries to permanent teeth. Part 3: Therapy of root fractures

Diagnostic and therapeutic interventions following dental injuries are not part of the routine practice in the dental office. Quite often, these patients are emergency cases who seek treatment after normal office hours. The objective of this and the future papers is to present the current treatment concepts in dental traumatology at the School of Dental Medicine, University of Berne. The fruitful cooperation in the field of dental traumatology between the Department of Oral Surgery and Stomatology, and the Department of Conservative Dentistry (including pediatric dentistry and endodontology), is based on the interdisciplinary approach that has been established four years ago. Following discussion and evaluation of such treated cases, and considering current clinical and experimental studies, the said concepts have been worked out. The present paper describes the therapeutic approach for root fractures.

Guidelines for the management of traumatic dental injuries. III. Primary teeth

Trauma to the primary dentition present special problems and the management is often different as compared with permanent teeth. An appropriate emergency treatment plan is important for a good prognosis. Guidelines are useful for delivering the best care possible in an efficient manner. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases in which the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the current best evidence based on literature research and professional opinion. In this third article out of three, the IADT Guidelines for the management of traumatic injuries in the primary dentition, are presented.

[Injuries to permanent teeth--Part 4: Therapy of crown fractures]

Diagnostic and therapeutic interventions following dental injuries are not part of the routine practice in the dental office. Quite often, these patients are emergency cases who seek treatment after normal office hours. The objective of this and the future papers is to present the current treatment concepts in dental traumatology at the School of Dental Medicine, University of Berne. The fruitful cooperation in the field of dental traumatology between the Department of Oral Surgery and Stomatology, and the Department of Conservative Dentistry (including pediatric dentistry and endodontology) is based on the interdisciplinary approach that has been established five years ago. Following discussion and evaluation of such treated cases, and considering current clinical and experimental references, the said concepts have been worked out. The present paper describes the therapeutic concepts of crown fractures.

Pulp and periodontal healing of laterally luxated permanent teeth: results after 4 years

AIM: To evaluate the pulp and periodontal healing of laterally luxated permanent teeth. MATERIAL AND METHODS: Patients presenting with lateral luxation of permanent teeth during 2001-2002 were enrolled in this clinical study. Laterally luxated teeth were repositioned and splinted with a TTS/composite resin splint for 4 weeks. Immediate (prophylactic) root-canal treatment was performed in severely luxated teeth with radiographically closed apices. All patients received tetracycline for 10 days. Re-examinations were performed after 1, 2, 3, 6, 12 and 48 months. RESULTS: All 47 laterally luxated permanent teeth that could be followed over the entire study period survived. In 10 teeth (21.3%), a prophylactic root-canal treatment was performed within 2 weeks following injury. The remaining 37 teeth showed the following characteristics at the 4-year re-examination: 19 teeth (51.4%) had pulp survival (no clinical or radiographic signs or symptoms), nine teeth (24.3%) presented with pulp canal calcification, and pulp necrosis was seen in another nine teeth (24.3%), within the first year after trauma. None of the teeth with a radiographically open apex at the time of lateral luxation showed complications. External root resorption was only seen in one tooth. CONCLUSIONS: Laterally luxated permanent teeth with incomplete root formation have a good prognosis, with all teeth surviving in this study. The most frequent complication was pulp necrosis that was only seen in teeth with closed apices.

Immediate and early non-occlusal loading of Straumann implants with a chemically modified surface (SLActive) in the posterior mandible and maxilla: interim results from a prospective multicenter randomized-controlled study

OBJECTIVE: Immediate and early loading of dental implants can simplify treatment and increase overall patient satisfaction. The purpose of this 3-year prospective randomized-controlled multicenter study was to assess the differences in survival rates and bone level changes between immediately and early-loaded implants with a new chemically modified surface (SLActive). This investigation shows interim results obtained after 5 months. MATERIAL AND METHODS: Patients > or =18 years of age missing at least one tooth in the posterior maxilla or mandible were enrolled in the study. Following implant placement, patients received a temporary restoration either on the day of surgery (immediate loading) or 28-34 days after surgery (early loading); restorations consisted of single crowns or two to four unit fixed dental prostheses. Permanent restorations were placed 20-23 weeks following surgery. The primary efficacy variable was change in bone level (assessed by standardized radiographs) from baseline to 5 months; secondary variables included implant survival and success rates. RESULTS: A total of 266 patients were enrolled (118 males and 148 females), and a total of 383 implants were placed (197 and 186 in the immediate and early loading groups, respectively). Mean patient age was 46.3+/-12.8 years. After 5 months, implant survival rates were 98% in the immediate group and 97% in the early group. Mean bone level change from baseline was 0.81+/-0.89 mm in the immediate group and 0.56+/-0.73 mm in the early group (P<0.05). Statistical analysis revealed a significant center effect (P<0.0001) and a significant treatment x center interaction (P=0.008). CONCLUSIONS: The results suggested that Straumann implants with an SLActive can be used predictably in time-critical (early or immediate) loading treatment protocols when appropriate patient selection criteria are observed. The mean bone level changes observed from baseline to 5 months (0.56 and 0.81 mm) corresponded to physiological observations from other studies, i.e., were not clinically significant. The presence of a significant center effect and treatment x center interaction indicated that the differences in bone level changes between the two groups were center dependent.

Comparison of intraoral radiography and limited cone beam computed tomography for the assessment of root-fractured permanent teeth

AIM: To compare intraoral occlusal (OC) and periapical (PA) radiographs vs. limited cone beam computed tomography (CBCT) in diagnosing root-fractured permanent teeth. MATERIAL AND METHODS: In 38 patients (mean age 24 years, range 8-52 years) with 44 permanent teeth with horizontal root fractures, intraoral radiographs (PA and OC) and limited CBCT were used to evaluate the location (apical, middle, cervical third of the root) and angulation of the fracture line. Furthermore, the conventional radiographs and CBCT images were compared for concordance of fracture location. RESULTS: In the PA and OC radiographs, 28 fractures (63.6%) were located in the middle third of the root, 11 (25.0%) in the apical third and 5 (11.4%) in the cervical third. The PA/OC radiographs and the sagittal CBCT images (facial aspect) yielded the same level of root fracture in 70.5% of cases (31 teeth; 95% CI: 54.1-82.7%). The PA/OC radiographs and sagittal CBCT images (palatal aspect) showed the same level of root fracture in 31.8% of cases. There was a statistically significant association between the angle at which the root fracture line intersected the axis of the tooth and the level of root fracture in the facial aspect of the sagittal CBCT images. CONCLUSIONS: The diagnosis of the location and angulation of root fractures based on limited CBCT imaging differs significantly from diagnostic procedures based on intraoral radiographs (PA/OC) alone. The clinical significance for treatment strategies and for the prognosis of root-fractured teeth has to be addressed in future studies.

Restoration margins in young adolescents: a clinical and radiographic study of Swiss Army recruits

PURPOSE: The aim of the present study was to report the radiographical prevalence of overhanging fillings in a group of Swiss Army recruits in 2006 and to relate the dimensions of the overhangs to clinical parameters. MATERIALS AND METHODS: A total of 626 Swiss Army recruits were examined for their periodontal conditions, prevalence of caries, and stomatological and functional aspects of the masticatory system and halitosis. In particular, the present report deals with the presence or the absence of fillings, the presence or the absence of overhangs and their relation to clinical and radiographic parameters. RESULTS: A total of 16,198 interdental sites were evaluated on bitewing radiographs. Of these sites, 15,516 (95.8%) were sound and 682 (4.2%) were filled. Amalgam restorations were found in 94.1% and resin composite fillings in 5.9% of the sites. Of these 682 sites, 96 (14.1%) yielded overhanging margins of various sizes. This low prevalence of fillings represents not only a substantial reduction when compared with a similar Swiss Army study (Lang et al, 1988), but also an improvement in the quality of dental care delivery to young Swiss males. Plaque Index and Gingival Index increased statistically significantly with the presence of fillings, when compared with healthy non-filled sites. Clinical parameters that were significantly associated with the presence of overhangs included clinical attachment loss. Moreover, between 1985 and 2006 the prevalence of fillings was significantly reduced from 20.0% to 4.2% of all surfaces. Furthermore, the marginal fit of the fillings improved from 33.0% with overhangs to 14.1%. CONCLUSIONS: A significant improvement was observed in the periodontal and dental conditions of young Swiss males that was shown to have taken place within the previous two decades. From 1985 to 2006, the prevalence of fillings was reduced fourfold and that of overhanging margins twofold, documenting an improvement in the quality of restorative dentistry.

In vivo bisphenol-a release from dental pit and fissure sealants: a systematic review

OBJECTIVE To search the literature and assess the short- and long-term release of bisphenol-A (BPA) in human tissues after treatment with dental sealants. DATA Two review authors performed data extraction independently and in duplicate using data collection forms. Disagreements were resolved by discussion with an arbiter. SOURCES Electronic database searches of published and unpublished literature were performed. The following electronic databases with no language and publication date restrictions were searched: MEDLINE (via Ovid and Pubmed), EMBASE (via ovid), Cochrane Trials Register and CENTRAL. The reference lists of all eligible studies were hand-searched. STUDY SELECTION In the absence of RCTs, six interventional and two observational studies, examining in vivo BPA release in human salivary, blood and urinary samples, were included. Due to the heterogeneity in methodology and reporting, the main synthesis of the results was qualitative. The quantitative synthesis based on the weighted Z-test could only include two studies. BPA levels identified in saliva ranged from traces below the method's detection limit to 30 μg/ml. In urine, BPA quantities spanned from 0.17 mg/g to 45.4 mg/g. BPA was not traced in any blood sample at any point of time in the relevant studies. The quantitative analysis showed evidence of BPA release one hour after sealant placement compared to the amount traced before restoration (Stouffer's z trend: <0.001). CONCLUSIONS The available evidence on this topic derived from studies that represent a moderate level of evidence. Nevertheless, the available evidence supports that BPA is released in saliva after sealant placement. CLINICAL SIGNIFICANCE From the qualititative and quantitative synthesis of studies, it is reasonable to conclude that BPA is released after placement of some dental pit and fissure sealants in the oral cavity. The biggest quantities are detected in saliva immediately after or one hour after their placement.

[The stamp technique for direct composite restoration]

The indications for direct resin composite restorations are nowadays extended due to the development of modern resin materials with improved material properties. However, there are still some difficulties regarding handling of resin composite material, especially in large restorations. The reconstruction of a functional and individual occlusion is difficult to achieve with direct application techniques. The aim of the present publication was to introduce a new "stamp"-technique for placing large composite restorations. The procedure of this "stamp"-technique is presented by three typical indications: large single-tooth restoration, occlusal rehabilitation of a compromised occlusal surface due to erosions and direct fibre-reinforced fixed partial denture. A step-by-step description of the technique and clinical figures illustrates the method. Large single-tooth restorations can be built-up with individual, two- piece silicone stamps. Large occlusal abrasive and/or erosive defects can be restored by copying the wax-up from the dental technician using the "stamp"-technique. Even fiber-reinforced resin-bonded fixed partial dentures can be formed with this intraoral technique with more precision and within a shorter treatment time. The presented "stamp"-technique facilitates the placement of large restoration with composite and can be recommended for the clinical use.

In vitro performance of a pen-type laser fluorescence device and bitewing radiographs for approximal caries detection in permanent and primary teeth.

AIM To evaluate the performance of a pen‑type laser fluorescence device (DIAGNOdent 2190; LFpen, KaVo, Germany) and bitewing radiographs (BW) for approximal caries detection in permanent and primary teeth. MATERIALS AND METHODS A total of 246 anterior approximal surfaces (102 permanent and 144 primary) were selected. Contact points were simulated using sound teeth. Two examiners assessed all approximal surfaces using LFpen and BW. The teeth were histologically assessed for the reference standard. Optimal cut‑off limits were calculated for LFpen for primary and permanent teeth. Sensitivity, specificity, accuracy and area under the receiver operating characteristic curve (Az) were calculated for D1 (enamel and dentin lesions) and D3 (dentin lesions) thresholds. The reproducibility was assessed by intraclass correlation coefficient (ICC) and Cohen's weighted kappa values. RESULTS For permanent teeth, the LFpen cut‑off were 0- 27 (sound), 28- 33 (enamel caries) and >33 (dentin caries). For primary teeth, the LFpen cut‑off were 0- 7 (sound), 8- 32 (enamelcaries) and >32 (dentin caries). The LFpen presented higher sensitivity values than BW for primary teeth (0.58 vs. 0.32 at D1 and 0.80 vs. 0.47 at D3) and permanent teeth (0.80 vs. 0.57 at D1 and 0.94 vs. 0.51 at D3). Specificity did not show a significant difference between the methods. Rank correlations with histology were 0.59 and 0.83 (LFpen) and 0.36 and 0.70 (BW) for primary and permanent teeth, respectively, considering all lesions. ICC values for LFpen were 0.71 (inter) and 0.86 (intra) for permanent teeth and 0.94 (inter) and 0.90/0.99 for primary teeth. Kappa values for BW were 0.69 (inter) and 0.68/0.90 (intra) for permanent teeth and 0.64 (inter) and 0.89/0.89 for primary teeth. CONCLUSION LFpen presented better reproducibility for primary and permanent teeth and higher accuracy in detecting caries lesions at D1 threshold than BW for permanent teeth. LFpen should be used as an adjunct method for approximal caries detection.

Is mental practice an effective adjunct therapeutic strategy for upper limb motor restoration after stroke?

Stroke is one of the most common conditions requiring rehabilitation, and its motor impairments are a major cause of permanent disability. Hemiparesis is observed by 80% of the patients after acute stroke. Neuroimaging studies showed that real and imagined movements have similarities regarding brain activation, supplying evidence that those similarities are based on the same process. Within this context, the combination of MP with physical and occupational therapy appears to be a natural complement based on neurorehabilitation concepts. Our study seeks to investigate if MP for stroke rehabilitation of upper limbs is an effective adjunct therapy. PubMed (Medline), ISI knowledge (Institute for Scientific Information) and SciELO (Scientific Electronic Library) were terminated on 20 February 2015. Data were collected on variables as follows: sample size, type of supervision, configuration of mental practice, setting the physical practice (intensity, number of sets and repetitions, duration of contractions, rest interval between sets, weekly and total duration), measures of sensorimotor deficits used in the main studies and significant results. Random effects models were used that take into account the variance within and between studies. Seven articles were selected. As there was no statistically significant difference between the two groups (MP vs Control), showed a – 0.6 (95% CI: –1.27 to 0.04), for upper limb motor restoration after stroke. The present meta-analysis concluded that MP is not effective as adjunct therapeutic strategy for upper limb motor restoration after stroke.

Oral Health Education Program on Dental Caries Incidence for School Children.

OBJECTIVE This 3-year retrospective controlled clinical trial assessed the effect of a school-based oral health education program on caries incidence in children. STUDY DESIGN A total of 240 students, aged 5 to 7 years, from two public schools in Monte Sião, Brazil, were included in this study. A school-based oral health education program was developed in one of the schools (experimental group), including 120 students, while the 120 students from the other school did not participate in the program (control group). All children were initially examined for dental caries (dmf-t), and after 3 years, 98 children from the experimental group and 96 from the control group were again examined and answered a questionnaire on oral health issues. The between-groups difference in caries incidence on permanent teeth was calculated using Poisson regression analyses. Logistic regression was used to observe the association between caries incidence and other variables. RESULTS More students from the experimental group stated knowing what was dental caries and declared that they use dental floss daily, but no significant differences in caries incidence was observed between the experimental and control groups. CONCLUSION The school-based oral health education program is not adequately efficient to decrease caries incidence after three years, but some issues about oral health knowledge could be slightly improved.

The timing of extraction of non-restorable first permanent molars: a systematic review.

AIM To identify the ideal timing of first permanent molar extraction to reduce the future need for orthodontic treatment. MATERIALS AND METHODS A computerised database and subsequent manual search was performed using Medline database, Embase and Ovid, covering the period from January 1946 to February 2013. Two reviewers (JE and ME) extracted the data independently and evaluated if the studies matched the inclusion criteria. Inclusion criteria were specification of the follow-up with clinical examination or analysis of models, specification of the chronological age or dental developmental stage at the time of extraction, no treatment in between, classification of the treatment result into perfect, good, average and poor. The search was limited to human studies and no language limitations were set. RESULTS The search strategy resulted in 18 full-text articles, of which 6 met the inclusion criteria. By pooling the data from maxillary sites, good to perfect clinical outcome was estimated in 72% (95% confidence interval 63%-82%). Extractions at the age of 8-10.5 years tended to show better spontaneous clinical outcomes compared to the other age groups. By pooling the data from mandibular sites, extractions performed at the age of 8-10.5 and 10.5-11.5 years showed significantly superior spontaneous clinical outcome with a probability of 50% and 59% likelihood, respectively, to achieve good to perfect clinical result (p<0.05) compared to the other age groups (<8 years of age: 34%, >11.5 years of age: 44%). CONCLUSION Prevention of complications after first permanent molars extractions is an important issue. The overall success rate of spontaneous clinical outcome for maxillary extraction of first permanent molars was superior to mandibular extraction. Extractions of mandibular first permanent molars should be performed between 8 and 11.5 years of age in order to achieve a good spontaneous clinical outcome. For the extraction in the maxilla, no firm conclusions concerning the ideal extraction timing could be drawn.

Prevalence and severity of dental fluorosis among students from João Pessoa, PB, Brazil

The aim of this study was to determine the prevalence and severity of dental fluorosis among 12-15-year-old students from João Pessoa, PB, Brazil before starting a program of artificial fluoridation of drinking water. The use of fluoridated dentifrice was also surveyed. A sample of 1,402 students was randomly selected. However, 31 students refused to participate and 257 were not permanent residents in João Pessoa, thus leaving a final sample of 1,114 students. Clinical exams were carried out by two calibrated dentists (Kappa = 0.78) under natural indirect light. Upper and lower front teeth were cleaned with gauze and dried, and then examined using the TF index for fluorosis. A questionnaire on dentifrice ingestion and oral hygiene habits was applied to the students. The results revealed that fluorosis prevalence in this age group was higher than expected (29.2%). Most fluorosis cases were TF = 1 (66.8%), and the most severe cases were TF = 4 (2.2%). The majority of the students reported that they had been using fluoridated dentifrices since childhood; 95% of the participants preferred brands with a 1,500 ppm F concentration, and 40% remembered that they usually ingested or still ingest dentifrice during brushing. It was concluded that dental fluorosis prevalence among students in João Pessoa is higher than expected for an area with non-fluoridated water. However, although most students use fluoridated dentifrices, and almost half ingest slurry while brushing, the majority of cases had little aesthetic relevance from the professionals' point of view, thus suggesting that fluorosis is not a public health problem in the locality.