Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 9/11/2009
Article title: Survey of Behavior Management Teaching in Pediatric Dentistry Advanced education Programs
Author(s): Adair SM, Rockman RA, et al
Journal: Pediatric Dentistry
Volume (number): 26:2, 151-8
Major topic: Survey of Behavior Management Techniques
Type of Article: Survey
Main Purpose: This study surveyed advanced Pediatric dentistry programs to determine teaching habits of communicative behavior management techniques as well as pharmacologic techniques.
Materials and Methods: Surveys were mailed to 65 programs. Questions addressed didactic teaching and clinical experience of residents and the answers were expressed as “not taught, “taught as acceptable”, and “taught as unacceptable”. 54 programs responded. Questions also included changes in the past 5 years and proposed changes in the next 3 years. Views on informed consent and presence of parents in the operatory were questioned as well
Findings: Most programs spend more than 20 classroom hours on behavior management with a mean of 13% of the time in didactic hours. TSD, VC, nonverbal, positive reinforcement, and distraction were taught and were acceptable. Only 28% teach HOME as acceptable, 54% teach as unacceptable. Active and passive immobilization, sedation, Nitrous, and general anesthesia were all taught as acceptable by most programs with slightly fewer reporting as acceptable for active immobilization with sedation. Of programs teaching HOME, 50% reported a decrease in time for teaching than they did 5 years ago, and 39% indicated they would spend less time teaching the technique in the future. Parents in operatory were routinely permitted for emergencies and special needs children. It was universally acceptable to have parents in the operatory for children under 3 years of age, while the number diminished as the children became older. Parents were present during routine exams in 56% of programs. Parents are excluded from sedation appointments in 41% of programs. Program directors noted an increase in frequency of parents in the operatory in the last 5 years and 70% of directors indicated no change in the future in their teaching of the acceptability of parents in the operatory. Reasons for the increase include parents request, ease of consultation with parents while treating the child, and concern over legal action. Written informed consent was used by almost all programs for nitrous oxide sedation and in all programs for general anesthesia. However, oral and written informed consent were used equally in conscious sedation
Key points/Summary : In summary, the majority of programs teach communicative and pharmacologic behavior management techniques as acceptable with the exception of HOME. Time spent in the curriculum of programs has not changed in the last 5 years nor is it anticipated that it will change in the next 2-3 years.
Assessment of article: Well presented article yielding expected results. Nothing earth shattering in this article.
Tuesday, September 8, 2009
An Analysis of Behavior Management Papers Published in the Pediatric Dental
Dan Boboia
Article Review 9/11/09
Title: An Analysis of Behavior Management Papers Published in the Pediatric Dental
Author: Stephen Wilson
Pediatric Dentistry 27:4, 2005
Purpose:
To categorize behavior management literature primarily published in Pediatric Dentistry and Journal of Dentistry for Children over the past 30 years to determine the quality of survey, opinion, and clinical publication types; also to focus on the specific techniques of behavior management, sanctioned by the AAPD, to determine the extent of evidence-based support for the techniques.
Methods:
A search of articles focusing on behavior management, but excluding sedation, was conducted of Pediatric Dentistry and the Journal of Dentistry for Children from 1970 to the present time. The publications were reviewed, data on authors, titles, and publication dates entered into a spreadsheet, and the publications divided into different types of analysis. The publications were divided into: opinion paper, survey or observation, clinical study.
Results:
168 articles were used. Less the 1/3 of the papers involved clinical studies. 38% were opinion papers. 32% were surveys or descriptions of behavior management in the dental setting. The number of clinical studies peaked in the mid 1980’s, and surveys have increased over the past decade.
Conclusions:
Numerous clinical studies, surveys, and opinions articles have been published on behavior management techniques. Most articles are opinion based, descriptive, or surveys. Less then 1/3 are based on clinical protocols incorporating the use sound scientific principles and methodology. There is minimal evidence derived from clinical studies on techniques used to control children’s behavior and responses to dentistry and published in the principal journals of our profession. Many questions still remain regarding the effectiveness and efficiency of clinical protocols associated with behavior management. The potential for future behavior management studies is great. The evidence-based data to support a clinical science of effectiveness of behavior management techniques in pediatric dentistry is limited and needs further development.
Assessment:
Good Article
Article Review 9/11/09
Title: An Analysis of Behavior Management Papers Published in the Pediatric Dental
Author: Stephen Wilson
Pediatric Dentistry 27:4, 2005
Purpose:
To categorize behavior management literature primarily published in Pediatric Dentistry and Journal of Dentistry for Children over the past 30 years to determine the quality of survey, opinion, and clinical publication types; also to focus on the specific techniques of behavior management, sanctioned by the AAPD, to determine the extent of evidence-based support for the techniques.
Methods:
A search of articles focusing on behavior management, but excluding sedation, was conducted of Pediatric Dentistry and the Journal of Dentistry for Children from 1970 to the present time. The publications were reviewed, data on authors, titles, and publication dates entered into a spreadsheet, and the publications divided into different types of analysis. The publications were divided into: opinion paper, survey or observation, clinical study.
Results:
168 articles were used. Less the 1/3 of the papers involved clinical studies. 38% were opinion papers. 32% were surveys or descriptions of behavior management in the dental setting. The number of clinical studies peaked in the mid 1980’s, and surveys have increased over the past decade.
Conclusions:
Numerous clinical studies, surveys, and opinions articles have been published on behavior management techniques. Most articles are opinion based, descriptive, or surveys. Less then 1/3 are based on clinical protocols incorporating the use sound scientific principles and methodology. There is minimal evidence derived from clinical studies on techniques used to control children’s behavior and responses to dentistry and published in the principal journals of our profession. Many questions still remain regarding the effectiveness and efficiency of clinical protocols associated with behavior management. The potential for future behavior management studies is great. The evidence-based data to support a clinical science of effectiveness of behavior management techniques in pediatric dentistry is limited and needs further development.
Assessment:
Good Article
Saturday, September 5, 2009
Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries –a review article.
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 9/04/2009
Article title: Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries –a review article.
Author(s): Andreasen JO, Andreasen FM, Skeie A, et al.
Journal: Dental Traumatol. 2002
Volume (number): 18: 116-128
Major topic: Dental Trauma Treatment timing
Type of Article: Review of Literature
Main Purpose: The purpose of this article was to evaluate clinical and experimental studies when a treatment delay factor was analyzed. These treatment timing factors were divided into acute (<3>24 hrs). The studies were selected from a Medline search.
Materials and Methods: The studies were evaluated according to the following types of injuries: Enamel/Dentin fractures, Complicated crown fractures including pulp exposures, Crown root fractures, Alveolar fractures, Concussion and subluxation, Extrusion and lateral luxation, Intrusion, Avulsions, and Primary tooth trauma.
Findings: Enamel/Dentin fractures: There are few symptoms reported, and aside from the occurrence of luxation complications, there is very low risk of pulp complications. Pulp complications occur in 1-3% of cases on average regardless of timing of treatment. Complicated crown fractures which include pulp exposures: It is common to have stimulated pain such as during mastication and temperature changes. If pulp caps or partial pulpotomy is the treatment of choice than no time relationship was show between treatment and pulpal healing. However, if cervical pulpotomy is planned then a subacute approach has a better prognosis for pulp healing. Crown/root fracture: In these cases, the coronal fragment should be removed and the pulp should be extirpated in its entirety especially if the root development is mature. Treatment has no relation to timing. Root fractures: Pain is usually related to tooth displacement. Studies indicate no proof of treatment timing as it relates to prognosis. Alveolar fractures: Pain is present during coclusion on displaced tooth bone segment. The two studies evaluated indicate healing of bone is good, but the PDL and pulp often develop complications. A strong relationship exists between treatment time and risk of pulpal necrosis was reported, but the studies were biased. Acute treatment timing is indicated. Concussion and subluxation: Pain to occlusion and mastication but not spontaneous. Mobility may be related. No conclusions could be drawn between this injury type and timing of treatment. Extrusion and lateral luxation: Although no study yielded a significant relationship between treatment timine and periodontal ligament healing, it was suggested that to reduce clinical symptoms. An acute or subacute treatment time is indicated. Root development seems to have more relevance in time of healing of pulpal or PDL tissue. Intrusion: This type of injury has the most severe pulpal and periodontal injury prognosis regardless of treatment timing. Treatment considerations include immedicate extrusion or delated extrusion Avulsions: Prognosis is reated to storage medium and length of extra-alveolar timing. Acute timing for reimplantation is essential, but splinting may occur in a subacute time frame. Primary tooth trauma: most injuries are lateral locations and intrusions. The extent of the injury determines the prognosis of the permanent tooth more so than the timing of treatment. An acute treatment approach is more appropriate for injuries affecting occlusion. Otherwise subacute treatment is warranted.
Key points/Summary : Few acute treatment indications are supported by the literature as it relates to dental trauma. Repositioning and splinting of teeth has a questionable prognosis when treatment timing is considered. However the immediacy of antibiotics to prevent dental infection appear to be appropriate.
Assessment of article: Lots of data to support the conclusion that we do not as dentists need to rush to the office to treat dental truama
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 9/04/2009
Article title: Effect of treatment delay upon pulp and periodontal healing of traumatic dental injuries –a review article.
Author(s): Andreasen JO, Andreasen FM, Skeie A, et al.
Journal: Dental Traumatol. 2002
Volume (number): 18: 116-128
Major topic: Dental Trauma Treatment timing
Type of Article: Review of Literature
Main Purpose: The purpose of this article was to evaluate clinical and experimental studies when a treatment delay factor was analyzed. These treatment timing factors were divided into acute (<3>24 hrs). The studies were selected from a Medline search.
Materials and Methods: The studies were evaluated according to the following types of injuries: Enamel/Dentin fractures, Complicated crown fractures including pulp exposures, Crown root fractures, Alveolar fractures, Concussion and subluxation, Extrusion and lateral luxation, Intrusion, Avulsions, and Primary tooth trauma.
Findings: Enamel/Dentin fractures: There are few symptoms reported, and aside from the occurrence of luxation complications, there is very low risk of pulp complications. Pulp complications occur in 1-3% of cases on average regardless of timing of treatment. Complicated crown fractures which include pulp exposures: It is common to have stimulated pain such as during mastication and temperature changes. If pulp caps or partial pulpotomy is the treatment of choice than no time relationship was show between treatment and pulpal healing. However, if cervical pulpotomy is planned then a subacute approach has a better prognosis for pulp healing. Crown/root fracture: In these cases, the coronal fragment should be removed and the pulp should be extirpated in its entirety especially if the root development is mature. Treatment has no relation to timing. Root fractures: Pain is usually related to tooth displacement. Studies indicate no proof of treatment timing as it relates to prognosis. Alveolar fractures: Pain is present during coclusion on displaced tooth bone segment. The two studies evaluated indicate healing of bone is good, but the PDL and pulp often develop complications. A strong relationship exists between treatment time and risk of pulpal necrosis was reported, but the studies were biased. Acute treatment timing is indicated. Concussion and subluxation: Pain to occlusion and mastication but not spontaneous. Mobility may be related. No conclusions could be drawn between this injury type and timing of treatment. Extrusion and lateral luxation: Although no study yielded a significant relationship between treatment timine and periodontal ligament healing, it was suggested that to reduce clinical symptoms. An acute or subacute treatment time is indicated. Root development seems to have more relevance in time of healing of pulpal or PDL tissue. Intrusion: This type of injury has the most severe pulpal and periodontal injury prognosis regardless of treatment timing. Treatment considerations include immedicate extrusion or delated extrusion Avulsions: Prognosis is reated to storage medium and length of extra-alveolar timing. Acute timing for reimplantation is essential, but splinting may occur in a subacute time frame. Primary tooth trauma: most injuries are lateral locations and intrusions. The extent of the injury determines the prognosis of the permanent tooth more so than the timing of treatment. An acute treatment approach is more appropriate for injuries affecting occlusion. Otherwise subacute treatment is warranted.
Key points/Summary : Few acute treatment indications are supported by the literature as it relates to dental trauma. Repositioning and splinting of teeth has a questionable prognosis when treatment timing is considered. However the immediacy of antibiotics to prevent dental infection appear to be appropriate.
Assessment of article: Lots of data to support the conclusion that we do not as dentists need to rush to the office to treat dental truama
Friday, September 4, 2009
Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident:Ray Murphy, Jr Date:8/28/09 Region: Prov.
Article title: Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth
Author(s): Flores, Marie. Lars Andersson, et al.
Journal: Dental Traumatology
Volume #; Number; Page #s): 23, 130-136
Year: 2007
Major topic: How to treat permanent teeth avulsions
Type of Article: Clinical Review
Main Purpose: Discuss treatment options and modalities for permanent teeth avulsions
Overview of method of research; Review of Treatment options
Findings. Dental trauma occurs in 5% of adult injuries, and as high as 18% of pre school children injury. Avulsions of permanent teeth are the most serious of all dental injuries. The measures that were taken at the time of the accident or immediately following the accident greatly affect the prognosis. An appropriate treatment plan, depending on the circumstances are crucial for a good prognosis. The International Association of Dental Traumatology(IADT) has developed a consensus review after referencing the most current literature and group discussions. The IADT does not guarantee favorable outcomes from following the guidelines, but using them can maximize the chance of success. Guidelines can be accessed at www.iadt-dentaltrauma.org. As dentists, it’s important for us to give appropriate advice to the public about first aid for avulsed. First aid for avulsed teeth include keeping the patient calm, handling the tooth by the crown only, rinsing it briefly for 10 seconds, placing the tooth in HBSS or milk, and seeking emergency treatment immediately for pulp testing, radiographs, and splinting. Radiographs should include a shot at a 90 degree angle, an occlusal, and lateral view.
Tooth Re-implanted Prior to Arrival
-Irrigate area-apply flexible splint-Administer antibiotics(doxycycline 2x daily for 1 week)-Tetanus shot if needed-Initiate RCT 7-10 days after reimplantation-Soft diet for 2 weeks, .1% Chlorhexidine Rinse daily
Tooth Kept in special storage <60 min
-Irrigate root surface and apical foramen with a stream of saline and place tooth in saline. -Reimplant tooth slowly, suture gingival lacerations-Follow tx above starting at admin. Antibiotics
Tooth avulsed>60 min.
-Poor prognosis-Goal is to promote alveolar bone growth to encapsulate tooth(possible ankylosis)-Scrape PDL and necrotic tissue off-RCT in hand before reimplantaion-Irrigate socket-Soak tooth in 2% NaF for 20 min-Reimplant, splint for 4 weeks-SEE ABOVE for AB tx, etc
Reimplanted w/ open apex
-Goal is revascularization-Clean area-Administer AB-Possible booster tetanus-Soft diet, soft brush, Chlorhexidine .1% for 1 week
Tooth stored in Medium <60
-Clean area-Cover root w/ arestin, etc-reimplant-SEE ABOVE for cont. tx
Extra oral time >60 min
-Poor prognosis-Same tx as closed apex
Follow up
-RCT
-Good outcomes include the tooth being asymp, normal mobility, no percussion sound, no radiographic pathology.
-Poor outcomes include symptoms of pain, increased mobility, high pitched percussion sound, radiographic pathology.
Assessment of article: Overall a great review article on treatment of avulsed permanent teeth
Dental Residency Program
Literature Review Form
Resident:Ray Murphy, Jr Date:8/28/09 Region: Prov.
Article title: Guidelines for the Management of Traumatic Dental Injuries II-Avulsion of Permanent Teeth
Author(s): Flores, Marie. Lars Andersson, et al.
Journal: Dental Traumatology
Volume #; Number; Page #s): 23, 130-136
Year: 2007
Major topic: How to treat permanent teeth avulsions
Type of Article: Clinical Review
Main Purpose: Discuss treatment options and modalities for permanent teeth avulsions
Overview of method of research; Review of Treatment options
Findings. Dental trauma occurs in 5% of adult injuries, and as high as 18% of pre school children injury. Avulsions of permanent teeth are the most serious of all dental injuries. The measures that were taken at the time of the accident or immediately following the accident greatly affect the prognosis. An appropriate treatment plan, depending on the circumstances are crucial for a good prognosis. The International Association of Dental Traumatology(IADT) has developed a consensus review after referencing the most current literature and group discussions. The IADT does not guarantee favorable outcomes from following the guidelines, but using them can maximize the chance of success. Guidelines can be accessed at www.iadt-dentaltrauma.org. As dentists, it’s important for us to give appropriate advice to the public about first aid for avulsed. First aid for avulsed teeth include keeping the patient calm, handling the tooth by the crown only, rinsing it briefly for 10 seconds, placing the tooth in HBSS or milk, and seeking emergency treatment immediately for pulp testing, radiographs, and splinting. Radiographs should include a shot at a 90 degree angle, an occlusal, and lateral view.
Tooth Re-implanted Prior to Arrival
-Irrigate area-apply flexible splint-Administer antibiotics(doxycycline 2x daily for 1 week)-Tetanus shot if needed-Initiate RCT 7-10 days after reimplantation-Soft diet for 2 weeks, .1% Chlorhexidine Rinse daily
Tooth Kept in special storage <60 min
-Irrigate root surface and apical foramen with a stream of saline and place tooth in saline. -Reimplant tooth slowly, suture gingival lacerations-Follow tx above starting at admin. Antibiotics
Tooth avulsed>60 min.
-Poor prognosis-Goal is to promote alveolar bone growth to encapsulate tooth(possible ankylosis)-Scrape PDL and necrotic tissue off-RCT in hand before reimplantaion-Irrigate socket-Soak tooth in 2% NaF for 20 min-Reimplant, splint for 4 weeks-SEE ABOVE for AB tx, etc
Reimplanted w/ open apex
-Goal is revascularization-Clean area-Administer AB-Possible booster tetanus-Soft diet, soft brush, Chlorhexidine .1% for 1 week
Tooth stored in Medium <60
-Clean area-Cover root w/ arestin, etc-reimplant-SEE ABOVE for cont. tx
Extra oral time >60 min
-Poor prognosis-Same tx as closed apex
Follow up
-RCT
-Good outcomes include the tooth being asymp, normal mobility, no percussion sound, no radiographic pathology.
-Poor outcomes include symptoms of pain, increased mobility, high pitched percussion sound, radiographic pathology.
Assessment of article: Overall a great review article on treatment of avulsed permanent teeth
Thursday, September 3, 2009
Avulsed permanent maxillary incisors
Resident’s Name: Joanne Lewis Date: September 4, 2009
Article title: Survival of avulsed permanent maxillary incisors in children following delayed replantation
Author(s): E. J. Barrett, D. J. Kenny
Journal: Endodontics and Dental Traumatology
Volume: 13
Date: 1997
Major topic: Avulsed permanent maxillary incisors
Type of Article: Research article
Main Purpose: To identify the variables that significantly influence the survival of incisors replanted after extended extraalveolar duration
Overview of method of research: 38 patients (25 males, 13 females) with a total of 52 reimplanted permanent maxillary incisors were included in the study. Only teeth in which reimplantation was delayed (more than 5 minutes between avulsion and reimplantation) were included in the study. A minimum follow-up time of 1 year was required for inclusion in the study. Prior to reimplantation, the teeth were held by the crown and cleaned with physiologic saline. The teeth were reimplanted and stabilized with a 0.014 or 0.016 stainless steel orthodontic wire. All patients were placed on a 7 day course of penicillin or erythromycin and given a follow-up appointment in 7 to 14 days. At the initial follow-up appointment, the splint was removed and endodontic therapy was initiated. Calcium hydroxide was placed in the canal and left for 6 to 24 months; the calcium hydroxide was replaced when follow-up radiographs revealed a loss of material from the root canal. The teeth were assessed periodically (3-6 weeks, 3 months, 6 months, 1 year) with radiographs and clinical exam. Root canal obturation with gutta percha and sealer was completed following treatment with calcium hydroxide for 6 to 24 months unless the replanted tooth had an open apex; teeth with open apices were treated with calcium hydroxide until apexification occurred.
Findings: The majority of teeth that failed were lost within the first 2 years. The relative risk of failure for incisors replanted with open apices was 4.2 times greater than for incisors replanted with closed apices. Replanted incisors that required prolonged treatment with calcium hydroxide were found to be 10 times more likely to fail than teeth that were obturated. Patients who were younger than 11 at the time of replantation showed decreased tooth survival.
Key points/Summary: Incisors with open apices showed significantly lower survival rates than did teeth with closed apices. The completion of root canal obturation had a significant influence on survival time.
Assessment of article: Interesting….I always thought an open apex would improve the prognosis.
Dental Trauma in Children: A Survey
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 9/04/2009
Article title: Dental Trauma in Children: A Survey
Author(s): Perez R, Berkowitz R. Mcllveen L. et al
Journal: Endodontic Dental Traumatology
Volume (number): 1991 (7): 212-3
Major topic: Dental Trauma
Type of Article: Survey
Main Purpose: The purpose of this article was to determine the type and prevalence of injuries presenting to the pediatric dental service of the Children’s National Medical Center in Washington D.C..
Materials and Methods: This twelve month study consisted of 227 patients who reported to the Children’s Medical Center with a traumatic dental injury. A clinical evaluation was performed and the indicated dental radiographs were exposed. Demographic information consisting of patient age, sex, time and cause of injury, intraoral and extraoral soft tissue injury, fractured or displaced teeth, and lastly alveolar fracture. All crown fractures were classified using Ellis classification and root fractures were noted. Displacements were divided as follows: Group 1—sensitivity to percussion and mobile without displacement; Group 2—extrusion from socket; Group 3 –intrusion; and lastly Group 4—avulsion.
Findings: Of the 227 patients, 96 were less than 5 years of age, 85 were 5-12 years, 46 were greater than 13. The leading cause of injury was due to falls at 46%. 132 (58%) children sustained soft tissue injury, approximately 33% sustained at least one fractured tooth, 62% sustained a displacement injury, and approximately 6% presented with an alveolar fracture which was usually associated with an automobile accident.
Key points/Summary : Falls were the most common cause of dental injury, males have a greater prevalence of dental trauma than females, injuries occur more frequently during the late spring, summer and early fall than other seasons. Soft tissue injury occurs in approximately half of all dental trauma.
Assessment of article: Well presented article yielding trauma patterns consistent with private practice
Lutheran Medical Center
Resident’s Name: Craig Elice Date: 9/04/2009
Article title: Dental Trauma in Children: A Survey
Author(s): Perez R, Berkowitz R. Mcllveen L. et al
Journal: Endodontic Dental Traumatology
Volume (number): 1991 (7): 212-3
Major topic: Dental Trauma
Type of Article: Survey
Main Purpose: The purpose of this article was to determine the type and prevalence of injuries presenting to the pediatric dental service of the Children’s National Medical Center in Washington D.C..
Materials and Methods: This twelve month study consisted of 227 patients who reported to the Children’s Medical Center with a traumatic dental injury. A clinical evaluation was performed and the indicated dental radiographs were exposed. Demographic information consisting of patient age, sex, time and cause of injury, intraoral and extraoral soft tissue injury, fractured or displaced teeth, and lastly alveolar fracture. All crown fractures were classified using Ellis classification and root fractures were noted. Displacements were divided as follows: Group 1—sensitivity to percussion and mobile without displacement; Group 2—extrusion from socket; Group 3 –intrusion; and lastly Group 4—avulsion.
Findings: Of the 227 patients, 96 were less than 5 years of age, 85 were 5-12 years, 46 were greater than 13. The leading cause of injury was due to falls at 46%. 132 (58%) children sustained soft tissue injury, approximately 33% sustained at least one fractured tooth, 62% sustained a displacement injury, and approximately 6% presented with an alveolar fracture which was usually associated with an automobile accident.
Key points/Summary : Falls were the most common cause of dental injury, males have a greater prevalence of dental trauma than females, injuries occur more frequently during the late spring, summer and early fall than other seasons. Soft tissue injury occurs in approximately half of all dental trauma.
Assessment of article: Well presented article yielding trauma patterns consistent with private practice
An analysis of 58 traumatically intruded and surgically extruded permanent teeth
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Kris Hendricks Date: September 4, 2009
Article title: An analysis of 58 traumatically intruded and surgically extruded permanent teeth
Author(s): K Ebeleseder, G Santler, K Glockner, H Hulla, C Perti, F Quehenberger
Journal: Endodontica and Dental Traumatology
Volume (number): 16: 34-39
Month, Year: 2000
Major topic: Trauma
Minor topic(s): Traumatically intruded teeth
Type of Article: Follow-up of traumatically intruded teeth
Main Purpose Analyze prognosis and sequelae of traumatically intruded teeth, some of which were surgically extruded
Overview of method of research: Traumatized teeth were treated and data was collected upon treatment, and at subsequent follow-up appointments. 29 teeth were followed for 9 months (short-term group), and 29 teeth were followed for 3 years 4 months.
Findings: Teeth in this study had varying degrees of trauma. Some were merely displaced, and others had crown fractures, alveolar bone fractures and gingival lacerations. Interestingly, the primary cause of intrusion luxated teeth in this study is the use of waterslides (cause #2 was cycling). Average age of patients was 11, and more males than females had injuries that met the criteria of the study. 48 of the 58 teeth were surgically repositioned (9 were inadvertently completely exarticulated), and 9 teeth with shallow intrusion depth and immature apices were left to spontaneously re-erupt. Orthodontic extrusion was done in one case. Of note, 54% of the teeth in the mid-term group showed discoloration and 9% of the short-term group, showing that discoloration increases with time lapsed since the injury. Teeth deeply intruded have poorer prognosis than those only slightly intruded. This study shows that immaturity of the root (e.g. open apex) had a positive influence on pulpal healing. Also, increasing surgical manipulation leads to increased incidence of ankylosis, but had no influence on pulpal healing or initial alveolar bone loss. The end of this study is a discussion on recommendations on treatment of intruded teeth. From other studies, Jacobsen recommends spontaneous re-eruption, Andreasen & Vestergaard-Pedersen recommend orthodontic repositioning, and Kinirons & Sutcliffe suggesst careful surgical repositioning.
Key points/Summary : In traumatically intruded teeth, talk to parents about discoloration, as it is common. Also, especially if deeply intruded, pulpal necrosis requiring endodontic treatment, and the possibility of ankylosis and marginal bone loss should be discussed. Possible need for future extraction should be mentioned as well.
Assessment of article: Good food for thought. Interestingly, this article cites its rationale for surgical reposition as “practical reasons.” Although in many cases it may be practical to surgically reposition teeth, the expectations of a good prognosis in dental traumatology are ever changing, and as ankylosis was the goal in years past, a healthy PDL and lack of ankylosis is the goal today. With that in mind, we should definitely consider other treatment options including spontaneous re-eruption, and orthodontic extrusion.
Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal healing
Resident: Adam J. Bottrill
Date: 04SEP09
Region: Providence
Article title: Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal healing.
Author(s): Andreasen JO, et al.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 76-89
Year: 1995
Major topic: Permanent incisor replantation
Minor topic(s): Periodontal ligament healing
Type of Article: Causal comparison
Main Purpose: Analyze the analyze factors related to the avulsion injury, extra-alveolar storage or subsequent treatment which contributed to periodontal ligament healing.
Overview of method of research: Prospective case comparison
Findings: Not telling.
Key points in the article discussion:
A. Past Studies: There have been many studies on PDL healing after replantation of avulsed teeth. The results of these studies suggest that the frequency of adequate PDL healing centers somewhere around 25% (but varies from 11% to 50%). No study has established definite relationships to extra-alveolar conditions or treatment factors. Typically, this is due to limited “n”.
1. There have been very conflicting results with studies concerning the effectiveness of saline storage after avulsion. This study will therefore, NOT examine the resorption-reducing effects of saline storage.
2. Often, retrospective studies reveal inaccurate charting. A PROSPECTIVE study is needed.
B. Clinical Materials and Methods:
1. 400 avulsed and subsequently replanted permanent incisors.
2. Clinical and radiographic evaluations.of the replanted
3. 5 categories of healing:
a. normal healing
b. surface resorption
c. inflammatory resorption
d. ankylosis
e. combination of the others
4. Many teeth eliminated from statistical analysis and presented independently.
a. extreme non-physiologic storage methods
b. double fractures (one tooth eliminated)
c. 272 teeth remained
5. First, analyzed for “significant” factors, then regression analysis using these variables to determine the interrelationship between the variables and “final risk.”
C. Results
1. PDL healing found in 26% (96 teeth) of the 400 and 25% (69 teeth) of the 272.
2. Chronology
a. surface resorption: 18 (4.5%) of the 400. Usually Dx no later than 12 mo.
b. inflammatory resorption: 120 (30%) of the 400. Usually Dx within first 6 mo. Sometimes secondary to ankylosis.
c. replacement resorption (anjylosis): 243 (61%) of the 400. Usually Dx by clinical findings at around 1-2 mo. Radiographically, only 212 ankylosed teeth observed and almost always AFTER clinical finding.
d. studies of short duration may be biased in that they would not catch resorption occurring after the study is complete.
3. PDL healing factors:
a. sex: NSF
b. tooth loc: NSF
c. crown fracture: NSF
d. age: PDL healing SIG less frequent in older people (>16)
e. root dev: PDL SIG less frequent with more advanced root development. Possibly due to thinning of the PDL as the tooth develops.
f. immediate replantation: MOST SIG increase of PDL healing in those that are immediately replanted (73% healing). Actually may just be a reflection of the ABSENCE of damage due to different types of unsatisfactory storage methods. Also, the value of rinsing avulsed teeth prior to replantation is still “unsettled.”
g. dry extra-alveolar storage: increasing dry storage time diminishes likelihood of PDL healing. “General time limit of 75 minutes”. Appears to be due to necrosis of PDL cells. After 90 minutes, only 10% of root surface covered by vital cells.
h. wet extra-alveolar storage: (saline or saliva) only extra-alveolar wet storage periods exceeding 20 minutes were accompanied by decreased PDL healing.
i. dry/wet storage: comb of dry AND wet storage resulted in SIG lower healing rate among teeth stored >20minutes.
j. dry/wet storage interaction: in teeth with dry storage <9>6 weeks showed increased resorption tendancy.
o. antibiotics: NSF
p. erupting teeth: increased potential for resorption
q. gingival healing: NSF
4. Using multivariate analysis, only 4 factors were found to be significantly related to PDL healing:
a. IMMEDIATE REPLANTATION (3)
b. DRY STORAGE PERIOD (2)
c. WET STORAGE PERIOD (4)
d. STAGE OF ROOT DEVELOPMENT (1)
5. Actual variation of probability of PDL healing is…. GET THIS!... 3% to 97% depending on the combination of factors!
D. Discussion
1. The fact that only 25% of teeth showed PDL healing (which matches the rate in previous studies) reflects the fact that the MAJORITY of teeth are handled incorrectly. This is shenanigans (i.e…. a bad thing).
2. IMMEDIATE reimplantation leads to approx 85-97% healing.
3. “In cases where immediate reimplantation cannot be carried out, the present study indicates no preference for storage in the oral cavity or in saline.”
Assessment of article: This article doesn’t mention Hank’s and only mentions the use of milk once. I don’t know when these methods were discovered, but I’m guessing this article was written prior to their discovery?
Date: 04SEP09
Region: Providence
Article title: Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal healing.
Author(s): Andreasen JO, et al.
Journal: Endodontics and Dental Traumatology
Volume #; Number; Page #s: Volume 11 pp: 76-89
Year: 1995
Major topic: Permanent incisor replantation
Minor topic(s): Periodontal ligament healing
Type of Article: Causal comparison
Main Purpose: Analyze the analyze factors related to the avulsion injury, extra-alveolar storage or subsequent treatment which contributed to periodontal ligament healing.
Overview of method of research: Prospective case comparison
Findings: Not telling.
Key points in the article discussion:
A. Past Studies: There have been many studies on PDL healing after replantation of avulsed teeth. The results of these studies suggest that the frequency of adequate PDL healing centers somewhere around 25% (but varies from 11% to 50%). No study has established definite relationships to extra-alveolar conditions or treatment factors. Typically, this is due to limited “n”.
1. There have been very conflicting results with studies concerning the effectiveness of saline storage after avulsion. This study will therefore, NOT examine the resorption-reducing effects of saline storage.
2. Often, retrospective studies reveal inaccurate charting. A PROSPECTIVE study is needed.
B. Clinical Materials and Methods:
1. 400 avulsed and subsequently replanted permanent incisors.
2. Clinical and radiographic evaluations.of the replanted
3. 5 categories of healing:
a. normal healing
b. surface resorption
c. inflammatory resorption
d. ankylosis
e. combination of the others
4. Many teeth eliminated from statistical analysis and presented independently.
a. extreme non-physiologic storage methods
b. double fractures (one tooth eliminated)
c. 272 teeth remained
5. First, analyzed for “significant” factors, then regression analysis using these variables to determine the interrelationship between the variables and “final risk.”
C. Results
1. PDL healing found in 26% (96 teeth) of the 400 and 25% (69 teeth) of the 272.
2. Chronology
a. surface resorption: 18 (4.5%) of the 400. Usually Dx no later than 12 mo.
b. inflammatory resorption: 120 (30%) of the 400. Usually Dx within first 6 mo. Sometimes secondary to ankylosis.
c. replacement resorption (anjylosis): 243 (61%) of the 400. Usually Dx by clinical findings at around 1-2 mo. Radiographically, only 212 ankylosed teeth observed and almost always AFTER clinical finding.
d. studies of short duration may be biased in that they would not catch resorption occurring after the study is complete.
3. PDL healing factors:
a. sex: NSF
b. tooth loc: NSF
c. crown fracture: NSF
d. age: PDL healing SIG less frequent in older people (>16)
e. root dev: PDL SIG less frequent with more advanced root development. Possibly due to thinning of the PDL as the tooth develops.
f. immediate replantation: MOST SIG increase of PDL healing in those that are immediately replanted (73% healing). Actually may just be a reflection of the ABSENCE of damage due to different types of unsatisfactory storage methods. Also, the value of rinsing avulsed teeth prior to replantation is still “unsettled.”
g. dry extra-alveolar storage: increasing dry storage time diminishes likelihood of PDL healing. “General time limit of 75 minutes”. Appears to be due to necrosis of PDL cells. After 90 minutes, only 10% of root surface covered by vital cells.
h. wet extra-alveolar storage: (saline or saliva) only extra-alveolar wet storage periods exceeding 20 minutes were accompanied by decreased PDL healing.
i. dry/wet storage: comb of dry AND wet storage resulted in SIG lower healing rate among teeth stored >20minutes.
j. dry/wet storage interaction: in teeth with dry storage <9>6 weeks showed increased resorption tendancy.
o. antibiotics: NSF
p. erupting teeth: increased potential for resorption
q. gingival healing: NSF
4. Using multivariate analysis, only 4 factors were found to be significantly related to PDL healing:
a. IMMEDIATE REPLANTATION (3)
b. DRY STORAGE PERIOD (2)
c. WET STORAGE PERIOD (4)
d. STAGE OF ROOT DEVELOPMENT (1)
5. Actual variation of probability of PDL healing is…. GET THIS!... 3% to 97% depending on the combination of factors!
D. Discussion
1. The fact that only 25% of teeth showed PDL healing (which matches the rate in previous studies) reflects the fact that the MAJORITY of teeth are handled incorrectly. This is shenanigans (i.e…. a bad thing).
2. IMMEDIATE reimplantation leads to approx 85-97% healing.
3. “In cases where immediate reimplantation cannot be carried out, the present study indicates no preference for storage in the oral cavity or in saline.”
Assessment of article: This article doesn’t mention Hank’s and only mentions the use of milk once. I don’t know when these methods were discovered, but I’m guessing this article was written prior to their discovery?
An evidence based appraisal of splinting luxated, avulsed and root fractured teeth
Resident’s Name: Brian Schmid DMD Date: 09/04/09
Article title: An evidence based appraisal of splinting luxated, avulsed and root fractured teeth
Author(s): Bill Kahler, Geoffrey Heithersay
Journal: Dental Traumatology
Month, Year: 2008
Major topic: Review of analyses for splinting recommendations post luxation, avulsion and root fracture injuries
Type of Article: Meta-analysis
Findings: Evidence based dentistry involves a search for current best evidence, a critical appraisal of the validity of the research. The paper goes on at length about selection bias, research ethics and appraisal of different kinds of studies. Originally splinting was inspired by jaw bone repair which included long term rigid splinting, but research began to show that this increased the chance of external resoption and pulpal necrosis. In other studies, a splinting time of 1 week showed the tooth to be firm. Current guidelines advise that avulsed teeth require a functional splint for 7-10 days. Recent studies show that the type of splint and splinting time are not significant variables in pulpal periodontal healing. For luxated and root fractured teeth functional splinting for a few weeks is now recommended. Multivariate analyses of the selected studies for this paper revealed that the treatment interventions are not generally significant variables when related to the healing outcome. Prognosis is best predicted by type of injury. In fact, some studies have shown no difference between splinting or not splinting in root fractured teeth but be wary since only teeth with no coronal dislocation were used. Currently for avulsed and replanted teeth only 7-10 days are recommended but longer duration may be required if a large amount of marginal bone was lost.
Key points/Summary: While there are many studies with multiple outcomes, it is still prudent to follow the normal recommendations for luxated, avulsed and root fractured teeth. Always be critical of outcomes as selection bias, limited scope and a variety of other problems can lead to a misapprehension. The prognosis of any trauma in best predicted by the type and degree of injury versus the splinting method.
Assessment of article: Mostly information about PICO and research issues, but it makes its point about closely criticizing articles which dictate treatment.
Article title: An evidence based appraisal of splinting luxated, avulsed and root fractured teeth
Author(s): Bill Kahler, Geoffrey Heithersay
Journal: Dental Traumatology
Month, Year: 2008
Major topic: Review of analyses for splinting recommendations post luxation, avulsion and root fracture injuries
Type of Article: Meta-analysis
Findings: Evidence based dentistry involves a search for current best evidence, a critical appraisal of the validity of the research. The paper goes on at length about selection bias, research ethics and appraisal of different kinds of studies. Originally splinting was inspired by jaw bone repair which included long term rigid splinting, but research began to show that this increased the chance of external resoption and pulpal necrosis. In other studies, a splinting time of 1 week showed the tooth to be firm. Current guidelines advise that avulsed teeth require a functional splint for 7-10 days. Recent studies show that the type of splint and splinting time are not significant variables in pulpal periodontal healing. For luxated and root fractured teeth functional splinting for a few weeks is now recommended. Multivariate analyses of the selected studies for this paper revealed that the treatment interventions are not generally significant variables when related to the healing outcome. Prognosis is best predicted by type of injury. In fact, some studies have shown no difference between splinting or not splinting in root fractured teeth but be wary since only teeth with no coronal dislocation were used. Currently for avulsed and replanted teeth only 7-10 days are recommended but longer duration may be required if a large amount of marginal bone was lost.
Key points/Summary: While there are many studies with multiple outcomes, it is still prudent to follow the normal recommendations for luxated, avulsed and root fractured teeth. Always be critical of outcomes as selection bias, limited scope and a variety of other problems can lead to a misapprehension. The prognosis of any trauma in best predicted by the type and degree of injury versus the splinting method.
Assessment of article: Mostly information about PICO and research issues, but it makes its point about closely criticizing articles which dictate treatment.
Wednesday, September 2, 2009
Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Resident: Roberts
Date: 9/4/09
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Journal: Pediatric Dentistry
Volume #30 Pages 197-205
Year: June 2008
Findings:
Most of the diagnostic test used in conventional endodontic therapy are of very little use when involving primary teeth and permanent immature teeth. Thus it is important for a clinician to understand normal root formation and exfoliation of primary teeth. Root development begins when enamel and dentin formation reach the CEJ. Hertwigs Epithelial root sheath is formed by the epithelial dental organ, with one tube for each root. As formation proceeds apically, the apices are wide open diverging apically. Once root length is established, odontoblast that line the internal surface begin to lay dentin until root formation is complete and the apices are closed. In permanent teeth root formation is not complete until 1-4 years after eruption into the oral cavity, in primary teeth it is a shorter duration. During this formative period, treatments should be oriented toward keeping the tooth vital until root formation is complete.
Young immature teeth: Loss of vitality before completion of root length will lead to a poorer crown to root ratio and weak roots leading to periodontal breakdown and possible fracture. Therefore, all treatment for this group should be geared towards maintaining pulpal vitality. EPT and thermal testing are of limited value when testing for pulp vitality in immature permanant teeth. Most diagnoses to these type of teeth occur from radiographic and clinical interpretation. Recently different materials used to treat immature teeth have also began to surface. MTA has recently been the scrutiny of much research. It has been shown to be more successful in stimulating tertiary dentin and maintaining pulpal vitality in direct pulp caps when compared to calcium hydroxide. It has also been proven to be an effective barrier for the treatment of open apex pulpless teeth. It has also been shown to be a be a better cemento-conductive material than calcium hydroxide allowing for stronger root formation in a shorter period of time.
Summary: When assessing primary and permanant immature teeth a clinician should be fully aware of growth and development of the dentition. A clinician should take every opportunity to keep a tooth vital when possible. Primary teeth should not be kept at the risk of damaging permanant teeth. When dealing with immature permanant teeth, one should look for ways to strengthen root formation. MTA has been proven to be a successful agent when dealing with these difficult circumstances.
Assessment of article: The article was good but I would have liked to have seen more discussion involving different materials.
Date: 9/4/09
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Journal: Pediatric Dentistry
Volume #30 Pages 197-205
Year: June 2008
Findings:
Most of the diagnostic test used in conventional endodontic therapy are of very little use when involving primary teeth and permanent immature teeth. Thus it is important for a clinician to understand normal root formation and exfoliation of primary teeth. Root development begins when enamel and dentin formation reach the CEJ. Hertwigs Epithelial root sheath is formed by the epithelial dental organ, with one tube for each root. As formation proceeds apically, the apices are wide open diverging apically. Once root length is established, odontoblast that line the internal surface begin to lay dentin until root formation is complete and the apices are closed. In permanent teeth root formation is not complete until 1-4 years after eruption into the oral cavity, in primary teeth it is a shorter duration. During this formative period, treatments should be oriented toward keeping the tooth vital until root formation is complete.
Young immature teeth: Loss of vitality before completion of root length will lead to a poorer crown to root ratio and weak roots leading to periodontal breakdown and possible fracture. Therefore, all treatment for this group should be geared towards maintaining pulpal vitality. EPT and thermal testing are of limited value when testing for pulp vitality in immature permanant teeth. Most diagnoses to these type of teeth occur from radiographic and clinical interpretation. Recently different materials used to treat immature teeth have also began to surface. MTA has recently been the scrutiny of much research. It has been shown to be more successful in stimulating tertiary dentin and maintaining pulpal vitality in direct pulp caps when compared to calcium hydroxide. It has also been proven to be an effective barrier for the treatment of open apex pulpless teeth. It has also been shown to be a be a better cemento-conductive material than calcium hydroxide allowing for stronger root formation in a shorter period of time.
Summary: When assessing primary and permanant immature teeth a clinician should be fully aware of growth and development of the dentition. A clinician should take every opportunity to keep a tooth vital when possible. Primary teeth should not be kept at the risk of damaging permanant teeth. When dealing with immature permanant teeth, one should look for ways to strengthen root formation. MTA has been proven to be a successful agent when dealing with these difficult circumstances.
Assessment of article: The article was good but I would have liked to have seen more discussion involving different materials.
Subscribe to:
Posts (Atom)