H. Nazzal

Interventions for the endodontic management of non-vital traumatised immature permanent anterior teeth in children and adolescents: a systematic review of the evidence and guidelines of the European Academy of Paediatric Dentistry

AimThis systematic review was undertaken in order to develop guidelines for the European Academy of Paediatric Dentistry for the management of non-vital permanent anterior teeth with incomplete root development.Methods Three techniques were considered; apexification by single or multiple applications of calcium hydroxide, use of Mineral Trioxide Aggregate (MTA) for the creation of an apical plug followed by obturation of the root canal, and finally a Regenerative Endodontic Technique (RET). Scottish Intercollegiate Guideline Network (SIGN) Guidelines (2008) were used for the synthesis of evidence and grade of recommendation.ResultsVariable levels of evidence were found and generally evidence related to these areas was found to be weak and of low quality. It was not possible to produce evidence-based guidelines based on the strength of evidence that is currently available for the management of non-vital immature permanent incisors.ConclusionsBased on the available evidence the European Academy of Paediatric Dentistry proposes Good Clinical Practice Points as a guideline for the management of such teeth. It is proposed that the long term use of calcium hydroxide in the root canals of immature teeth should be avoided and apexification with calcium hydroxide is no longer advocated. The evidence related to the use of a Regenerative Endodontic Technique is currently extremely weak and therefore this technique should only be used in very limited situations where the prognosis with other techniques is deemed to be extremely poor. The current review supports the use of MTA followed by root canal obturation as the treatment of choice.

Regenerative endodontics: a true paradigm shift or a bandwagon about to be derailed?

AimsRegenerative endodontic techniques (RETs) have been hailed as a paradigm shift for the management of traumatised non-vital immature permanent anterior teeth. In this article the aim was to critically appraise the literature with regards to the outcome of regenerative endodontics on root development.MethodsCritical review of the literature where regenerative endodontic techniques have been used in the management of immature non-vital teeth with continuation of root development as the main outcome reported.ResultsMost studies published were in the form of case reports and series with very few randomised controlled trials with a high risk of bias. Continuation of root development following the use of RET has been shown to be unpredictable at best with lower success in those teeth losing vitality as a result of dental trauma.ConclusionsDespite the high success of regenerative endodontics in terms of periodontal healing including resolution of clinical and radiographic signs and symptoms of infection, continuation of root development remains an unpredictable outcome. The use of a blood clot as a scaffold in regenerative endodontics should be reviewed carefully as that might offer an environment for repair rather than regeneration. In addition, preservation of structures, such as Hertwig’s epithelial root sheath, may have an important bearing on the success of this approach and should be further investigated.

Regenerative Endodontic Therapy in the Management of Nonvital Immature Permanent Teeth: A Systematic Review—Outcome Evaluation and Meta-analysis

Introduction Although the protocols in previously published studies appeared to be largely similar, there were inadequate evidence‐based guidelines to support a single protocol. Using a meta‐analysis, this systematic review aimed to summarize and quantitatively evaluate the outcomes for nonvital immature permanent teeth treated using the regenerative endodontic technique (RET) as well as critically appraise the level and quality of evidence of the existing publications. Methods Risk of bias assessment and level of evidence grading were performed on all included studies. Meta‐analyses using a random effects model were performed to combine the results of randomized controlled trials. The pooled success rate for each exposure was estimated for each outcome (event rates with 95% confidence intervals). The outcomes of all included studies were summarized. Results Success rates for tooth survival and resolution of periapical pathosis were excellent; however, results for apical closure and continued root development were inconsistent. There are few well‐reported randomized prospective clinical studies. Reporting of long‐term outcomes and late‐stage effects was sparse. No study evaluated health economic outcomes and improvements to patients’ quality of life. Conclusions Many knowledge gaps still exist within the studies published. Current published evidence is unable to provide definitive conclusions on the predictability of RET outcomes. HighlightsThe success rates for tooth survival and resolution of periapical pathology were excellent.The results for apical closure and continued root development were inconsistent.There are few well‐reported randomized prospective clinical studies.The reporting of long‐term outcomes and late‐stage effects was sparse.No study evaluated health economic outcomes and improvements to patients’ quality of life.

An unusual presentation of erythema multiforme in a paediatric patient.

BackgroundErythema multiforme (EM) is an acute, vesiculobullous disease of skin and mucous membranes with symptoms ranging from mild to severe. A complex interaction of different factors has been implicated the condition; the majority with a preceding herpes simplex infection. This report describes an unusual presentation of erythema multiforme affecting the lips and oral mucosa of a healthy 7-year-old boy in the form of lip adherence.Case reportTwo weeks following eruption of oral ulcerations, a 7-year-old healthy boy developed severe erosive ulceration of both lips, causing complete lip adherence. This was accompanied by marked bilateral submandibular and cervical lymphadenopathy, tremor and sweating. Clinical and laboratory investigations led to a diagnosis of erythema multiforme. The patient was treated initially with gentle application of Vaseline between the lips using cotton buds in an attempt to release lip adhesion, followed by surgical release of the lips under general anaesthesia. Analgesics and topical steroid mouthwash were provided.Follow-upSeven months later, the patient presented with a recurrence of his EM which included lesions on the skin. The patient was treated with antivirals, topical and systematic steroids to suppress the recurrent attacks of EM. Eighteen months following the initial presentation the patient and parent reported considerable decrease in the frequency, severity and duration of the occurrence of intra-oral ulcers, with no major episode of target lesions on the skin.ConclusionErythema multiforme is rare in children, however it should be considered in the differential diagnosis of recurrent erosive oral ulcerative lesions especially when the oral lesions resemble those of primary herpetic gingivostomatitis.

Regenerative endodontic therapy (RET) for managing immature non-vital teeth: a national survey of UK paediatric dental specialists and trainees

Background Several guidelines have been published advocating the use of regenerative endodontic therapy (RET) in managing non-vital immature permanent teeth. It is unclear, however, how many UK paediatric dental specialists routinely use this technique and their opinion of its outcomes, and barriers to its use.Aim To assess the knowledge, experience and the opinion of UK based paediatric dental specialists/trainees (UKPDS/T) and practitioners working in the capacity of paediatric dental specialists on the use of RET.Design A cross-sectional study using a 22-item questionnaire was developed using the Bristol Online Survey tool and circulated electronically to members of the British Society of Paediatric Dentistry between August and November 2016.Results Ninety-eight UKPDS/T completed the survey. A quarter of respondents (N = 24, 24.5%) reported using RET. Reasons cited for not using RET included lack of: training (N = 48, 45%), materials (N = 28, 26%), evidence (N = 17, 16%) and suitable cases (N = 6, 6%). Different protocols in terms of disinfection, medicaments, scaffolds, and obturation material were identified.Conclusions This survey highlights a low uptake of RET by current UKPDS and trainees with several barriers identified. Deviations from the current RET guidelines were identified. Recommendations addressing the use of RET in light of the findings of this survey were made.

A biocompatible decellularized pulp scaffold for regenerative endodontics

AIM To investigate the feasibility of decellularizing the entire dental pulp using a mild treatment protocol to develop a decellularized biological extracellular matrix scaffold for use in regenerative endodontic procedures. METHODOLOGY Decellularized human dental pulps were assessed using histological and immunohistochemical methods, scanning electron microscope and DNA quantification assay. Cytotoxicity assays to determine decellularized scaffold biocompatibility were also performed. Decellularized scaffolds were seeded with human dental pulp stem cells and cell viability assessed using Live/Dead® stain. Quantitative data were analysed statistically using Students t-test and one-way analysis of variance to compare mean values between groups depending on group numbers. RESULTS Assessment of decellularized tissues revealed an acellular matrix with preservation of native tissue histoarchitecture and composition. Decellularized tissues showed no evidence of cytotoxicity, with cell growth in direct contact with the scaffold and no reduction in cellular activity following extract incubation. Furthermore, the scaffold was able to support human dental pulp stem cell viability and attachment following recellularization. CONCLUSIONS Promising results were observed in developing a decellularized biological scaffold derived from the dental pulp with the perseveration of extracellular structural components which are required for tissue-specific regeneration.

Defects of Dentin Development

The management of children with defects of dentin can be challenging from both diagnostic and treatment perspectives. Obtaining the correct diagnosis is based on careful evaluation of the family history, clinical manifestations and radiographic appearance. Therefore, this chapter aims at describing the various types of conditions leading to defects in dentin with emphasis on the importance of establishing a holistic treatment plan that encompasses a stepwise approach to help achieve the short-, medium- and long-term treatment goals of a functional and aesthetic dentition.

Restorative Management of Dental Enamel Defects in the Primary Dentition

Many genetic and environmental conditions can interfere with the normal development of primary teeth and can manifest as defects in the enamel. Such defects can be associated with pain and discomfort and can have esthetic implications which may affect the young child’s self-esteem. It is not only important for clinicians to be able to diagnose the defects but also to understand the implications these might have on restorative techniques and materials they choose. Restorative management can be challenging because of the limited cooperation in some children, the extent of the defects, and the sensitivity that may be present. The main aims of treatment should be to alleviate pain and sensitivity, improve esthetics, and manage any other concerns that the child or the parents might have. This should be followed by consideration of long-term treatment planning involving progression of the primary through to the mixed dentition. In many cases, especially where there is a genetic component with generalized involvement of both the primary and subsequent permanent teeth, an interdisciplinary approach to management is appropriate. Finally it is important to be able to provide treatment in a manner the child finds acceptable. This chapter helps the reader identify and effectively manage primary teeth with commonly encountered enamel defects.

Interdisciplinary management of severe intrusion injuries in permanent incisors: a case series

Intrusion injuries to the permanent dentition are amoung the most severe types of dental injuries, occurring in 0.3-1.9% of all dental trauma cases. The current clinical guidelines in the management of intrusion injuries are based on level B evidence due to the infrequent nature of this type of injury, coupled with a lack of high quality evidence-based studies. This paper presents four cases of severe intrusion injuries that were successfully managed using an interdisciplinary approach. The cases described here highlight the benefits of orthodontic repositioning of severely intruded teeth in the short and medium terms. Although orthodontic repositioning was unsuccessful in the final case, this did not preclude subsequent surgical repositioning. Interdisciplinary collaboration allowed two of the cases described to be effectively managed with premolar autotransplantation alongside orthodontic treatment. The cases demonstrated here indicate the difficulties in providing the current recommended treatment modalities at non-specialist clinics. They accentuate the importance of an immediate referral of such complex cases to a specialist centre where interdisciplinary management is readily available.