[Dens invaginatus. Review of the literature and diagnostic and therapeutic guidelines]

Dens invaginatus is a clinically relevant malformation of teeth resulting from an infolding of enamel and dentine into the dental structure during tooth formation, hence the former denomination "dens in dente". The dens invaginatus shows multiple morphological variations of crown and root formation. This frequently leads to caries, pulpal and periodontal involvement with necrosis and loss of attachment. Therefore, early diagnosis and prevention are of utmost importance. Due to the complexity of the malformation, treatment options in former days were limited. This article presents a profound review of the literature regarding etiology, epidemiology and histology. It discusses clinical appearance and diagnosis and it provides guidelines for decision-making and treatment of invaginated teeth.

Quantification of dental erosions in patients with GERD using optical coherence tomography before and after double-blind, randomized treatment with esomeprazole or placebo

OBJECTIVES: Dental erosion, the chemical dissolution of enamel without bacterial involvement, is a rarely reported manifestation of gastroesophageal reflux disease (GERD), as well as of recurrent vomiting and dietary habits. It leads to loss of tooth substance, hypersensitivity, functional impairment, and even tooth fracture. To date, dental erosions have been assessed using only very basic visual methods, and no evidence-based guidelines or studies exist regarding the prevention or treatment of GERD-related dental erosions. METHODS: In this randomized, double-blind study, we used optical coherence tomography (OCT) to quantify dental tissue demineralization and enamel loss before and after 3 weeks of acid-suppressive treatment with esomeprazole 20 mg b.i.d. or placebo in 30 patients presenting to the Berne University Dental Clinic with advanced dental erosions and abnormal acid exposure by 24-h esophageal pH manometry (defined as >4% of the 24-h period with pH<4). Enamel thickness, reflectivity, and absorbance as measures of demineralization were quantified by OCT before and after therapy at identical localizations on teeth with most severe visible erosions as well as several other predefined changes in teeth. RESULTS: The mean+/-s.e.m. decrease of enamel thickness of all teeth before and after treatment at the site of maximum exposure was 7.2+/-0.16 black trianglem with esomeprazole and 15.25+/-0.17black trianglem with placebo (P=0.013), representing a loss of 0.3% and 0.8% of the total enamel thickness, respectively. The change in optical reflectivity to a depth of 25 black trianglem after treatment was-1.122 +/-0.769 dB with esomeprazole and +2.059+/-0.534 dB with placebo (P 0.012), with increased reflectivity signifying demineralization. CONCLUSIONS: OCT non-invasively detected and quantified significantly diminished progression of dental tissue demineralization and enamel loss after only 3 weeks of treatment with esomeprazole 20 mg b.i.d. vs. placebo. This suggests that esomeprazole may be useful in counteracting progression of GERD-related dental erosions. Further validation of preventative treatment regimens using this sensitive detection method is required, including longer follow-up and correlation with quantitative reflux measures.

Dental injuries in association with facial fractures

PURPOSE: The aim of the study was to investigate the association between dental injuries and facial fractures. MATERIALS AND METHODS: We performed a prospective study of 273 patients examined at a level 1 trauma center in Switzerland from September 2005 until August 2006 who had facial fractures. Medical history and clinical and radiologic examination findings were recorded to evaluate demographics, etiology, presentation, and type of facial fracture, as well as its relationship to dental injury site and type. RESULTS: In 273 patients with dentition, we recorded 339 different facial fractures. Of these patients, 130 (47.5%) sustained a fracture in the non-tooth-bearing region, 44 (16%) had a fractured maxilla, and 65 (24%) had a fractured mandible. Among 224 patients with dentition who had a facial fracture in only 1 compartment, 140 injured teeth were found in 50 patients. Of 122 patients with an injury limited to the non-tooth-bearing facial skeleton, 12 sustained dental trauma (10%). In patients with fractures limited to the maxilla (n = 41), 6 patients had dental injuries (14.5%). In patients with fractures to the mandible (n = 61), 24 sustained dental injuries (39%). When we compared the type of tooth lesion and the location, simple crown fractures prevailed in both jaws. Patients with a fracture of the mandible were most likely to have a dental injury (39.3%). The highest incidence of dental lesions was found in the maxilla in combination with fractures of the lower jaw (39%). This incidence was even higher than the incidence of dental lesions in the lower jaw in combination with fractures of the mandible (24%). CONCLUSIONS: Knowledge of the association of dental injuries and maxillofacial fractures is a basic tool for their prevention. Our study showed that in cases of trauma with mandibular fracture, the teeth in the upper jaw might be at higher risk than the teeth in the lower jaw. Further larger-scale studies on this topic could clarify this finding and may provide suggestions for the amelioration of safety devices (such as modified bicycle helmets).

Management of children with autism spectrum disorder in the dental setting: concerns, behavioural approaches and recommendations

OBJECTIVES This article reviews the present literature on the issues encountered while coping with children with autistic spectrum disorder from the dental perspective. The autistic patient profile and external factors affecting the oral health status of this patient population are discussed upon the existing body of evidence. MATERIAL AND METHODS The MEDLINE database was searched using the terms 'Autistic Disorder', 'Behaviour Control/methods', 'Child', 'Dental care for disabled', 'Education', 'Oral Health', and 'Pediatric Dentistry' to locate related articles published up to January 2013. RESULTS Most of the relevant studies indicate poor oral hygiene whereas they are inconclusive regarding the caries incidence in autistic individuals. Undergraduate dental education appears to determine the competence of dental professionals to treat developmentally disabled children and account partly for compromised access to dental care. Dental management of an autistic child requires in-depth understanding of the background of the autism and available behavioural guidance theories. The dental professional should be flexible to modify the treatment approach according to the individual patient needs.

Performance of experienced dentists in Switzerland after an e-learning program on ICDAS occlusal caries detection

This study aimed to evaluate the effect of an e-learning program on the validity and reproducibility of the International Caries Detection and Assessment System (ICDAS) in detecting occlusal caries. For the study, 170 permanent molars were selected. Four dentists in Switzerland who had no previous contact with ICDAS examined the teeth before and after the e-learning program and scored the sites according to ICDAS. Teeth were histologically prepared and assessed for caries extension. The significance level was set at 0.05. Sensitivity before and after the e-learning program was 0.80 and 0.77 (D1), 0.72 and 0.63 (D2), and 0.74 and 0.67 (D3,4), respectively. Specificity was 0.64 and 0.69 (D1), 0.70 and 0.81 (D2), and 0.81 and 0.87 (D3,4). A McNemar test did not show any difference between the values of sensitivity, specificity, accuracy, and area under the ROC curve (AUC) before and after the e-learning program. The averages of wK values for interexaminer reproducibility were 0.61 (before) and 0.66 (after). Correlation with histology presented wK values of 0.62 (before) and 0.63 (after). A Wilcoxon test showed a statistically significant difference between before and after the e-learning program. In conclusion, even though ICDAS performed well in detecting occlusal caries, the e-learning program did not have any statistically significant effect on its performance by these experienced dentists.

Effects of buffering properties and undissociated acid concentration on dissolution of dental enamel in relation to pH and acid type

To quantify the relationships between buffering properties and acid erosion and hence improve models of erosive potential of acidic drinks, a pH-stat was used to measure the rate of enamel dissolution in solutions of citric, malic and lactic acids, with pH 2.4-3.6 and with acid concentrations adjusted to give buffer capacities (β) of 2-40 (mmol·l(-1))·pH(-1) for each pH. The corresponding undissociated acid concentrations, [HA], and titratable acidity to pH 5.5 (TA5.5) were calculated. In relation to β, the dissolution rate and the strength of response to β varied with acid type (lactic > malic ≥ citric) and decreased as pH increased. The patterns of variation of the dissolution rate with TA5.5 were qualitatively similar to those for β, except that increasing pH above 2.8 had less effect on dissolution in citric and malic acids and none on dissolution in lactic acid. Variations of the dissolution rate with [HA] showed no systematic dependence on acid type but some dependence on pH. The results suggest that [HA], rather than buffering per se, is a major rate-controlling factor, probably owing to the importance of undissociated acid as a readily diffusible source of H(+) ions in maintaining near-surface dissolution within the softened layer of enamel. TA5.5 was more closely correlated with [HA] than was β, and seems to be the preferred practical measure of buffering. The relationship between [HA] and TA5.5 differs between mono- and polybasic acids, so a separate analysis of products according to predominant acid type could improve multivariate models of erosive potential.

Restorative dentistry and restorative materials over the next 20 years: A Delphi survey

OBJECTIVES The aim of this study was to forecast trends in restorative dentistry over the next 20 years and to identify treatment goals and corresponding properties of restorative materials. METHODS Using the Delphi method, a panel of 3 experts identified 8 key questions, which were sent to experts in restorative and preventive dentistry. In round 1 of this survey, 15 international experts devised a clearer semantic definition of the key questions and the completion of respective items for two additional rounds. In round 2, 125 experts from 35 countries rated the items developed in round 1 using a Likert scale. In round 3, the same 125 experts received the ratings of round 2 and were asked to agree or disagree to these ratings by re-voting on all key questions and items. A total of 105 experts re-voted and finally took part in the complete survey. Among the 8 key questions, two questions were selected for the present report: (Q1) "What will be the future role of restorative treatment?" and (Q6) "What will be the key qualities for clinical success of restorations?" For both questions and the respective items, the experts were asked to evaluate the importance and the feasibility for later calculation of the scientific value (i.e. the opportunity, where opportunity=importance+[importance-feasibility]). RESULTS The three items of highest importance for Q1 were "preservation of existing enamel and dentin tissue," "prevention of secondary caries," and "maintenance of the pulp vitality," and for Q6 they were "optimization of adhesion," "biocompatibility," and "minimizing technical sensitivity." SIGNIFICANCE Bioactivity toward the pulp-dentin complex and prevention of secondary caries were the items generally rated as having the highest opportunity.

CECOG experts' recommendations on the use of denosumab in the prevention of skeletal-related events in bone metastases of lung cancer

Purpose Skeletal-related events represent a substantial burden for patients with advanced cancer. Randomized, controlled studies suggested superiority of denosumab over zoledronic acid in the prevention of skeletal-related events in metastatic cancer patients, with a favorable safety profile. Experts gathered at the 2012 Skeletal Care Academy in Istanbul to bring forward practical recommendations, based on current evidence, for the use of denosumab in patients with bone metastases of lung cancer. Recommendations Based on current evidence, use of denosumab in lung cancer patients with confirmed bone metastases is recommended. It is important to note that clinical judgment should take into consideration the patient’s general performance status, overall prognosis, and live expectancy. Currently, the adverse event profile reported for denosumab includes hypocalcemia and infrequent occurrence of osteonecrosis of the jaw. Therefore, routine calcium and vitamin D supplementation, along with dental examination prior to denosumab initiation are recommended. There is no evidence for renal function impairment due to denosumab administration. At present, there is no rationale to discourage concomitant use of denosumab and surgery or radiotherapy.

Psychometric and biohormonal indices of dental anxiety in children. A prospective cohort study.

The stress of dental treatment often elicits negative emotions in children, expressed as dental fear or anxiety. Highly anxious children obstruct treatment and avoid therapy, further amplifying oral health problems. The aim of this study was to examine the neuroendocrine and autonomic nervous system responses to dental treatment and their possible interactions and associations with psychometric indices of anxiety, caries, previous dental experience, anesthesia, age and gender in school children. Upon informed consent, saliva was obtained from 97 children (59% males, mean age ±  SD: 89.73 ± 15 months) in the Clinic of pediatric dentistry before treatment, immediately post-treatment and at the recall visit to determine cortisol and salivary alpha-amylase (sAA) levels. Dental and general anxiety was assessed through specific questionnaires completed by the children. Compared to pre-treatment, cortisol levels were increased following treatment, while sAA levels were higher at the recall. Pre- and post-treatment cortisol and sAA responses were positively correlated. Dental and general anxiety questionnaire scores were also significantly correlated with each other. The integrated autonomic and neuroendocrine responses prior to treatment were correlated with state anxiety and those following treatment with dental anxiety. However, univariable and multivariable linear regression analysis associated post-treatment cortisol, but not sAA, levels with dental anxiety. No associations of cortisol or sAA responses with caries, age, gender, previous dental experience or anesthesia were detected. These data provide some evidence that both sAA and cortisol levels are altered in children in anticipation or during dental treatment, but only cortisol levels are associated to dental anxiety.

Assessment of smoking behaviour in a dental setting: a 1-year follow-up study using self-reported questionnaire data and exhaled carbon monoxide levels.

OBJECTIVES This study analyses the changes in smoking habits over the course of 1 year in a group of patients referred to an oral medicine unit. MATERIALS AND METHODS Smoking history and behaviour were analysed at baseline and after 1 year based on a self-reported questionnaire and on exhaled carbon monoxide levels [in parts per million (ppm)]. During the initial examination, all smokers underwent tobacco use prevention and cessation counselling. RESULTS Of the initial group of 121 patients, 98 were examined at the follow-up visit. At the baseline examination, 33 patients (33.67 %) indicated that they were current smokers. One year later, 14 patients (42.24 % out of the 33 smokers of the initial examination) indicated that they had attempted to stop smoking at least once over the follow-up period and 15.15 % (5 patients) had quit smoking. The mean number of cigarettes smoked per day by current smokers decreased from 13.10 to 12.18 (p = 0.04). The exhaled CO level measurements showed very good correlation with a Spearman's coefficient 0.9880 for the initial visit, and 0.9909 for the follow-up examination. For current smokers, the consumption of one additional cigarette per day elevated the CO measurements by 0.77 ppm (p < 0.0001) at the baseline examination and by 0.84 ppm (p < 0.0001) at the 1-year follow-up. CONCLUSIONS In oral health care, where smoking cessation is an important aspect of the treatment strategy, the measurement of exhaled carbon monoxide shows a very good correlation with a self-reported smoking habit. CLINICAL RELEVANCE Measurement of exhaled carbon monoxide is a non-invasive, simple and objective measurement technique for documenting and monitoring smoking cessation and reduction.

Dental erosive wear assessment among adolescents and adults utilizing the basic erosive wear examination (BEWE) scoring system.

OBJECTIVES To investigate erosive tooth wear and related variables among adolescents and adults in Israel, utilizing the new basic erosive wear examination (BEWE) scoring system, in an attempt to contribute to the ongoing review, evaluation, and further development of an international standardized index. MATERIAL AND METHODS A cross-sectional, descriptive, and analytic survey was conducted among 500 subjects of five age groups. Dental erosion was measured according to the new BEWE scoring system. Independent variables included gender, age, origin, education, employment status, and diet. A backward stepwise linear regression model was applied to identify significantly associated variables. RESULTS Fifty percent of the survey subjects demonstrated erosive tooth wear; among them, 10 % had distinct erosion of over 50 % of the dental surface. Total BEWE score differences by age groups were statistically significant; as the age increased, the mean total BEWE scores increased (p < 0.001). The association between acidic foods and erosion was evident among the younger population (p = 0.038). In a multiple regression model, age (p < 0.001) and diet (p = 0.044) achieved statistical significance as variables associated with dental erosive wear. CONCLUSIONS Our study is one of the first to use the BEWE scoring system in an epidemiological survey among adolescents and adults. It was found that the BEWE index is straightforward, easy to conduct, and comfortably accepted by the examinees. CLINICAL RELEVANCE The present findings, together with further international research, should contribute toward continued evaluation of the BEWE system as an international standard and thereby, toward more optimal understanding, evidence-based treatment, and prevention of dental erosive wear.

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.

All-ceramic or metal-ceramic tooth-supported fixed dental prostheses (FDPs)? A systematic review of the survival and complication rates. Part II: Multiple-unit FDPs.

OBJECTIVE To assess the 5-year survival of metal-ceramic and all-ceramic tooth-supported fixed dental prostheses (FDPs) and to describe the incidence of biological, technical and esthetic complications. METHODS Medline (PubMed), Embase and Cochrane Central Register of Controlled Trials (CENTRAL) searches (2006-2013) were performed for clinical studies focusing on tooth-supported FDPs with a mean follow-up of at least 3 years. This was complemented by an additional hand search and the inclusion of 10 studies from a previous systematic review [1]. Survival and complication rates were analyzed using robust Poisson's regression models to obtain summary estimates of 5-year proportions. RESULTS Forty studies reporting on 1796 metal-ceramic and 1110 all-ceramic FDPs fulfilled the inclusion criteria. Meta-analysis of the included studies indicated an estimated 5-year survival rate of metal-ceramic FDPs of 94.4% (95% CI: 91.2-96.5%). The estimated survival rate of reinforced glass ceramic FDPs was 89.1% (95% CI: 80.4-94.0%), the survival rate of glass-infiltrated alumina FDPs was 86.2% (95% CI: 69.3-94.2%) and the survival rate of densely sintered zirconia FDPs was 90.4% (95% CI: 84.8-94.0%) in 5 years of function. Even though the survival rate of all-ceramic FDPs was lower than for metal-ceramic FDPs, the differences did not reach statistical significance except for the glass-infiltrated alumina FDPs (p=0.05). A significantly higher incidence of caries in abutment teeth was observed for densely sintered zirconia FDPs compared to metal-ceramic FDPs. Significantly more framework fractures were reported for reinforced glass ceramic FDPs (8.0%) and glass-infiltrated alumina FDPs (12.9%) compared to metal-ceramic FDPs (0.6%) and densely sintered zirconia FDPs (1.9%) in 5 years in function. However, the incidence of ceramic fractures and loss of retention was significantly (p=0.018 and 0.028 respectively) higher for densely sintered zirconia FDPs compared to all other types of FDPs. CONCLUSIONS Survival rates of all types of all-ceramic FDPs were lower than those reported for metal-ceramic FDPs. The incidence of framework fractures was significantly higher for reinforced glass ceramic FDPs and infiltrated glass ceramic FDPs, and the incidence for ceramic fractures and loss of retention was significantly higher for densely sintered zirconia FDPs compared to metal-ceramic FDPs.

Primary prevention of peri-implantitis: managing peri-implant mucositis

AIMS Over the past decades, the placement of dental implants has become a routine procedure in the oral rehabilitation of fully and partially edentulous patients. However, the number of patients/implants affected by peri-implant diseases is increasing. As there are--in contrast to periodontitis--at present no established and predictable concepts for the treatment of peri-implantitis, primary prevention is of key importance. The management of peri-implant mucositis is considered as a preventive measure for the onset of peri-implantitis. Therefore, the remit of this working group was to assess the prevalence of peri-implant diseases, as well as risks for peri-implant mucositis and to evaluate measures for the management of peri-implant mucositis. METHODS Discussions were informed by four systematic reviews on the current epidemiology of peri-implant diseases, on potential risks contributing to the development of peri-implant mucositis, and on the effect of patient and of professionally administered measures to manage peri-implant mucositis. This consensus report is based on the outcomes of these systematic reviews and on the expert opinion of the participants. RESULTS Key findings included: (i) meta-analysis estimated a weighted mean prevalence for peri-implant mucositis of 43% (CI: 32-54%) and for peri-implantitis of 22% (CI: 14-30%); (ii) bleeding on probing is considered as key clinical measure to distinguish between peri-implant health and disease; (iii) lack of regular supportive therapy in patients with peri-implant mucositis was associated with increased risk for onset of peri-implantitis; (iv) whereas plaque accumulation has been established as aetiological factor, smoking was identified as modifiable patient-related and excess cement as local risk indicator for the development of peri-implant mucositis; (v) patient-administered mechanical plaque control (with manual or powered toothbrushes) has been shown to be an effective preventive measure; (vi) professional intervention comprising oral hygiene instructions and mechanical debridement revealed a reduction in clinical signs of inflammation; (vii) adjunctive measures (antiseptics, local and systemic antibiotics, air-abrasive devices) were not found to improve the efficacy of professionally administered plaque removal in reducing clinical signs of inflammation. CONCLUSIONS Consensus was reached on recommendations for patients with dental implants and oral health care professionals with regard to the efficacy of measures to manage peri-implant mucositis. It was particularly emphasized that implant placement and prosthetic reconstructions need to allow proper personal cleaning, diagnosis by probing and professional plaque removal.

Impact of different magnification levels on visual caries detection with ICDAS

OBJECTIVES The aim of this in vitro study was to examine the effect of different levels of magnification on the accuracy and reliability of visual caries detection using ICDAS criteria. METHODS Occlusal surfaces of 100 extracted molars were assessed by 14 examiners (3rd and the 4th year dental students and dentists) using no magnification aids, a 2.5× Galilean loupe, a 4.5× Keplerian loupe, or a surgical microscope with 10× magnification. The assessments were repeated on a different day. Sensitivity, specificity, AUC and reliabilities were calculated according to the gold standard of histology. RESULTS We found that with increasing magnification, the number of surfaces rated as "sound" (ICDAS code 0) decreased, while the number of surfaces with a localized enamel breakdown (ICDAS code 3) increased. While the sensitivities increased, the values of the specificities decreased to an unacceptably low level irrespective of the clinical experience of the examiners. CONCLUSIONS ICDAS seems to be optimized for natural vision up to 2.0× magnification and not for high magnifications. The use of powerful magnification in visual caries detection involves the risk of unnecessary and premature invasive treatment. CLINICAL SIGNIFICANCE This paper discusses when it does and does not make sense to use magnification devices for visual caries detection using ICDAS criteria. Strong magnifications should be refrained from for this purpose.