Resident: Adam J. Bottrill
Date: 20OCT10
Region: Providence
Article title: Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache is Changing, Especially in Young, Immature Teeth
Author(s): Camp, Joe DDS MSD
Journal: Pediatric Dentistry
Page #s: 197-205
Date: May/Jun 2008, V30:No3
Major topic: Immature Tooth Vital Pulp Therapy
Minor topic(s): NA
Type of Article: Review of Literature
Main Purpose: Reviews the available literature and current techniques of indirect pulp therapy, pulp capping, and pulpotomy for primary teeth and permanent teeth with open apezx. The apical barrier with mineral trioxide aggregate followed by root strengthening with bonded composite is reviewed.
Key points in the article discussion:
I. General:
A. Most of the diagnostic tests used used with endodontic therapy are of little to no value on primary teeth or immature permanent teeth.
B. Much of our Tx decisions are based on Dx of root development age... therefore it is necessary to have thorough knowledge of the rot development timeline for primary and permanent teeth.
1. Root formation is not completed for 1-4 years after eruption into the oral cavity.
C. Radiographs cannot accurately depict apical closure due to the development of canals in the lingual-facial direstion.
D. During formation and closure, Tx must be oriented at maintaining vitality and allowing the completion of root formation.
II. Dx of Pulpal Status in Primary Teeth.
A. Differentiation between provoked and spontaneous pain is vital.
1. Provoked: deep caries, faulty restorations, soreness around exfoliation and erupting permanent teeth.
2. Spontaneous: extensive degenerative changes extending into the root canals... should NOT receive vital pulp Tx. There may be other evidence of pulpal pathosis as well... mobility, fistula, percussive sensitivity etc...
B. ELECTRIC PULP TESTS ARE NOT VALID ON PRIMARY TEETH.
C. THERMAL TESTS ARE USUALLY NOT CONDUCTED ON PRIMARY TEETH.
D. Radiographic exam is necessary
1. Calcified masses are a sign of advanced pulpal degeneration... Pulpectomization or Extraction.
2. Internal resorption is also associated with extensive inflammation... Extraction.
3. Keep in mind the lucency of the succedaneous follicle.
4. Other obvious pathosis... fracture, abscess, bone fractures etc...
E. Excessive or oddly colored hemorrhage is evidence of excessive inflammation.
F. Studies have shown that trauma LIKELY will result in pulpal necrosis or at least pulpal obliteration (depending on degree of trauma, luxation, mobility etc...)
G. AVULSED PRIMARY TEETH SHOULD NOT BE REIMPLANTED.
H. About half of traumatized primary teeth will undergo discoloration.
1. Correlation of type of color change to pulpal health is controversial and inconclusive.
III. Diagnosis of Pulpal Status in Permanent Immature Teeth
A. Loss of pulp vitality before completion of root formation leaves the tooth MUCH more susceptible to root fracture.
B. Again, a history should be taken WRT history of trauma and type of pain etc...
C. Clinical and radiographic examination MOST important when diagnosing immature permanent teeth.
D. Electric pulp test and thermal test not reliable for immature, open apex teeth... also for children.
E. Electrical and Thermal tests unreliable for traumatized teeth.
F. Laser doppler flowmetry reportedly very reliable to diagnose pulpal vitality.
G. Discoloration also usually indicative of pulpal changes but not completely accurate.
H. There is MUCH better potential for an immature tooth to heal after trauma.
I. If doubtful of diagnosis, DO NOT start treatment. Attempt to allow formation of the root until definitive diagnosis can be made.
J. Lately, MTA and composite resins have been replacing CaOH, pulp cappng and pulpotomy.
K. Vital treatment of teeth with MTA, once considered taboo, is being used much more often in order to allow continued root formation.
L. Revascularization of necrotic pulps has even been reported using combinations of AB's.
M. And of course... he had to mention stem cells.
Assessment of article: Good Summary
Showing posts with label diagnosis. Show all posts
Showing posts with label diagnosis. Show all posts
Tuesday, October 19, 2010
Thursday, August 20, 2009
The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Resident: Adam J. Bottrill
Date: 21AUG09
Region: Providence
Article title: The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Author(s): Holan, Gideon DMD et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 24:1 pp: 38-42
Year: 2002
Major topic: Diagnostic radiographs for intruded maxillary primary incisors.
Minor topic(s): None
Type of Article: Comparative diagnostic study.
Main Purpose: Assess the contribution of a lateral extraoral radiograph for diagnosing the relation between the root of intruded maxillary primary incisors and their permanent successors.
Overview of method of research: Quantitative, clinically diagnostic study.
Findings: N/A
Key points in the article discussion: Intrusive luxation has been found by some authors to be the most common type of injury to the primary incisor region. The proximity of the primary incisor to the labial surface of the permanent successor increases the risk of damage to the developing bud from trauma. It is therefore very important to determine the relation between the root of the intruded primary root and the permanent successor.
A. Methods
1. Study group: all children with intruded primary incisors who presented to XC clinic of the Dept of Ped Dent at the Hadassah School of Dental Medicine in Jerusalem, Israel.
a. 18 mo period.
b. 37 children with 55 intruded primary incisors.
c. age: 8 to 63 mo.
d. 56% were partially intruded and 44% completely disappeared in to tissue.
e. 29 pts (w/ 44 teeth) checked within 2 days
f. 60% w/ only 1 intruded tooth. Rest had 2 or more.
g. 93 total 3-step evaluations were available.
2. Teeth intruded more than 7 days are not included in the study.
3. Three steps for root relationship assessment.
a. Clinical exam: Inspection of tooth, and soft/hard tissue surrounding the intruded tooth.
b. PA evaluation: (and sometimes repeating step 1)
c. Lateral extraoral radiograph evaluation:
4. Clinical signs include:
a. hematoma presence
b. projection of labial bone plate
c. relative elongating or shortening of teeth.
d. “unable to assess”
5. Assessments are made independently
6. LATERAL RADIOGRAPH WAS CONSIDERED “CONTRIBUTORY” IF A FINAL DECISION COULD NOT BE MADE WITHOUT STEP 3, OR IF IT DIFFERED FROM THAT MADE FOLLOWING THE 1ST AND 2ND STEPS.
7. Ability to assess the tooth alignment following steps 2 and 3 was statistically analyzed using the McNemar test.
B. Results
1. Assessment was possible in 86% of step 1; 62% of step 2; 42% of step 3. All others were “unable to assess.”
2. In only 5 (5%) of evaluations was step #3 found “contributory.”
3. DIFFERENCE IN EVAUATORS ABILITY TO ASSESS POSITION AFTER STEP 3 VS AFTER STEP 2 WAS NOT STATISTICALLY SIGNIFICANT.
4. Separate evaluations made for:
a. Intrusion of single vs multiple teeth, central vs lateral, partially vs completely intruded, less than vs more than 20mo.,
b. no statistically significant differences in any of these parameters existed.
5. When useful, lateral radiographs were MORE useful when assessing single-tooth intrusions and central intrusions.
6. Also, lateral radiographs were more useful in pt’s under 20 mo.
a. this may be due to the overall difficulty in assessing the position as well as the low radiodensity of permanent succesors.
7. In the case of any evaluator disagreement, 5 of the 6 disagreements occurred in step 3.
Summary of conclusions: In the case of intrusion of maxillary primary incisors, the contribution of the lateral extraoral radiograph in determining the alignment of the root of intruded teeth is LOW.
A. Possible explanations:
1. Overlap, errors in aligning the cone correctly.
2. When evaluating the lateral radiograph alone, one can only clearly Dx when the root of the intruded tooth has been significantly displaced labially. OTHERWISE NO CONCLUSION CAN BE MADE.
3. Should still attempt to Dx based on PA radiograph and not clinical exam alone.
a. gap between intruded tooth and permanent successor.
b. shortened, more opaque image of intruded incisor
c. lack of rotation of the permanent successor
B. Finally:
1. Lateral extraoral radiographs should not be used routinely in cases of intrusion of primary incisors. Lateral radiographs should only be taken when it’s expected contribution can be confirmed by other methods.
Assessment of article: Applicable and well organized. This topic has the potential to be controversial as it seems we have all been instructed at some point in our education to use these lateral radiographs as a diagnostic tool.
Date: 21AUG09
Region: Providence
Article title: The diagnostic value of lateral extraoral radiography for intruded maxillary primary incisors.
Author(s): Holan, Gideon DMD et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s: Volume 24:1 pp: 38-42
Year: 2002
Major topic: Diagnostic radiographs for intruded maxillary primary incisors.
Minor topic(s): None
Type of Article: Comparative diagnostic study.
Main Purpose: Assess the contribution of a lateral extraoral radiograph for diagnosing the relation between the root of intruded maxillary primary incisors and their permanent successors.
Overview of method of research: Quantitative, clinically diagnostic study.
Findings: N/A
Key points in the article discussion: Intrusive luxation has been found by some authors to be the most common type of injury to the primary incisor region. The proximity of the primary incisor to the labial surface of the permanent successor increases the risk of damage to the developing bud from trauma. It is therefore very important to determine the relation between the root of the intruded primary root and the permanent successor.
A. Methods
1. Study group: all children with intruded primary incisors who presented to XC clinic of the Dept of Ped Dent at the Hadassah School of Dental Medicine in Jerusalem, Israel.
a. 18 mo period.
b. 37 children with 55 intruded primary incisors.
c. age: 8 to 63 mo.
d. 56% were partially intruded and 44% completely disappeared in to tissue.
e. 29 pts (w/ 44 teeth) checked within 2 days
f. 60% w/ only 1 intruded tooth. Rest had 2 or more.
g. 93 total 3-step evaluations were available.
2. Teeth intruded more than 7 days are not included in the study.
3. Three steps for root relationship assessment.
a. Clinical exam: Inspection of tooth, and soft/hard tissue surrounding the intruded tooth.
b. PA evaluation: (and sometimes repeating step 1)
c. Lateral extraoral radiograph evaluation:
4. Clinical signs include:
a. hematoma presence
b. projection of labial bone plate
c. relative elongating or shortening of teeth.
d. “unable to assess”
5. Assessments are made independently
6. LATERAL RADIOGRAPH WAS CONSIDERED “CONTRIBUTORY” IF A FINAL DECISION COULD NOT BE MADE WITHOUT STEP 3, OR IF IT DIFFERED FROM THAT MADE FOLLOWING THE 1ST AND 2ND STEPS.
7. Ability to assess the tooth alignment following steps 2 and 3 was statistically analyzed using the McNemar test.
B. Results
1. Assessment was possible in 86% of step 1; 62% of step 2; 42% of step 3. All others were “unable to assess.”
2. In only 5 (5%) of evaluations was step #3 found “contributory.”
3. DIFFERENCE IN EVAUATORS ABILITY TO ASSESS POSITION AFTER STEP 3 VS AFTER STEP 2 WAS NOT STATISTICALLY SIGNIFICANT.
4. Separate evaluations made for:
a. Intrusion of single vs multiple teeth, central vs lateral, partially vs completely intruded, less than vs more than 20mo.,
b. no statistically significant differences in any of these parameters existed.
5. When useful, lateral radiographs were MORE useful when assessing single-tooth intrusions and central intrusions.
6. Also, lateral radiographs were more useful in pt’s under 20 mo.
a. this may be due to the overall difficulty in assessing the position as well as the low radiodensity of permanent succesors.
7. In the case of any evaluator disagreement, 5 of the 6 disagreements occurred in step 3.
Summary of conclusions: In the case of intrusion of maxillary primary incisors, the contribution of the lateral extraoral radiograph in determining the alignment of the root of intruded teeth is LOW.
A. Possible explanations:
1. Overlap, errors in aligning the cone correctly.
2. When evaluating the lateral radiograph alone, one can only clearly Dx when the root of the intruded tooth has been significantly displaced labially. OTHERWISE NO CONCLUSION CAN BE MADE.
3. Should still attempt to Dx based on PA radiograph and not clinical exam alone.
a. gap between intruded tooth and permanent successor.
b. shortened, more opaque image of intruded incisor
c. lack of rotation of the permanent successor
B. Finally:
1. Lateral extraoral radiographs should not be used routinely in cases of intrusion of primary incisors. Lateral radiographs should only be taken when it’s expected contribution can be confirmed by other methods.
Assessment of article: Applicable and well organized. This topic has the potential to be controversial as it seems we have all been instructed at some point in our education to use these lateral radiographs as a diagnostic tool.
Wednesday, February 18, 2009
Clinical decision making for caries management in children
Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Derek Banks Date: February 20, 2009
Article title: Clinical decision making for caries management in children
Author(s): N Tinanoff, J Douglass
Journal: AAPD Journal
Volume (number): 24:386-392
Month, Year: 2002
Major topic: Pit and fissure caries
Minor topic(s): Diagnosis
Type of Article: Position paper
Main Purpose: Discuss decision making for caries management in children
Overview of method of research: Review
Findings: A few factors should be taken into consideration when treating caries: 1. Location and extent of the lesions, 2. patient’s age, 3. Assessment and reassessment of disease activity, 4. prior therapy outcomes, 5. natural history of caries progression, and 6. preferences and expectations of guardians and practitioners. Studies show that the earlier a child becomes colonized with s. mutans, the greater their caries risk. We can assess this with microbiological tests, but when carious lesions are already present in young children (especially on upper incisors and molar proximal surfaces) it goes without saying that these patients are high caries risk. When determining whether to take preventative measures or perform operative dentistry, one factor to consider is that buccal-lingual smooth surface lesions respond better to these regimens than cavitated fissure/proximal lesions. A few studies demonstrated the average growth rate of proximal enamel-only lesions, showing that in primary teeth it takes about a year for them to spread to the dentin. Permanent proximal lesions took from one to three years. Many different modalities are available for the diagnosis of dental caries, but although they may have high specificity (ability to rule out caries), none have a high sensitivity (ability to confirm the presence of caries. Interestingly, a study showed that bitewing radiographs showed better sensitivity than clinical exam in pit/fissure caries extending to the dentin. This paper mentions the fact that in in-tact sealant can seal-in and “deactivate” caries… as long as the integrity of the sealant maintains. This paper mentions risk factors for caries which include low birth weight, age of colonization, s.mutans levels, presence of visible plaque, and sociodemogaphic factors. Toothbrushing and avoiding sweets make sense on a microbiological level, but have yet to be proven in in vivo longitudinal studies. This paper recommends fluoride supplementation only in non-fluoridated communities in moderate-to-high risk patients whose parents understand risks and benefits. We should focus instead on the topical effects of fluoride. Toothbrushing is lauded mainly for its ability to deliver fluoride – moreso than for it’s plaque-reduction, interestingly enough.
Key points/Summary : This paper is best summed up by it’s recommendation that “dental care should be based on preventive services and supplemented by restorative therapy only when indicated.”
Assessment of article: Good position paper.
Lutheran Medical Center
Resident’s Name: Derek Banks Date: February 20, 2009
Article title: Clinical decision making for caries management in children
Author(s): N Tinanoff, J Douglass
Journal: AAPD Journal
Volume (number): 24:386-392
Month, Year: 2002
Major topic: Pit and fissure caries
Minor topic(s): Diagnosis
Type of Article: Position paper
Main Purpose: Discuss decision making for caries management in children
Overview of method of research: Review
Findings: A few factors should be taken into consideration when treating caries: 1. Location and extent of the lesions, 2. patient’s age, 3. Assessment and reassessment of disease activity, 4. prior therapy outcomes, 5. natural history of caries progression, and 6. preferences and expectations of guardians and practitioners. Studies show that the earlier a child becomes colonized with s. mutans, the greater their caries risk. We can assess this with microbiological tests, but when carious lesions are already present in young children (especially on upper incisors and molar proximal surfaces) it goes without saying that these patients are high caries risk. When determining whether to take preventative measures or perform operative dentistry, one factor to consider is that buccal-lingual smooth surface lesions respond better to these regimens than cavitated fissure/proximal lesions. A few studies demonstrated the average growth rate of proximal enamel-only lesions, showing that in primary teeth it takes about a year for them to spread to the dentin. Permanent proximal lesions took from one to three years. Many different modalities are available for the diagnosis of dental caries, but although they may have high specificity (ability to rule out caries), none have a high sensitivity (ability to confirm the presence of caries. Interestingly, a study showed that bitewing radiographs showed better sensitivity than clinical exam in pit/fissure caries extending to the dentin. This paper mentions the fact that in in-tact sealant can seal-in and “deactivate” caries… as long as the integrity of the sealant maintains. This paper mentions risk factors for caries which include low birth weight, age of colonization, s.mutans levels, presence of visible plaque, and sociodemogaphic factors. Toothbrushing and avoiding sweets make sense on a microbiological level, but have yet to be proven in in vivo longitudinal studies. This paper recommends fluoride supplementation only in non-fluoridated communities in moderate-to-high risk patients whose parents understand risks and benefits. We should focus instead on the topical effects of fluoride. Toothbrushing is lauded mainly for its ability to deliver fluoride – moreso than for it’s plaque-reduction, interestingly enough.
Key points/Summary : This paper is best summed up by it’s recommendation that “dental care should be based on preventive services and supplemented by restorative therapy only when indicated.”
Assessment of article: Good position paper.
Subscribe to:
Posts (Atom)