Louise Brearley Messer

Clinical Studies on Molar-Incisor-Hypomineralisation Part 1: Distribution and Putative Associations

Aim: This was to describe the distributions of affected first permanent molars (FPMs) in a sample of children with molar-incisor-hypomineralisation (MIH) and molar hypomineralisation (MH), and to examine their perinatal and medical histories for putative associations with molar hypomineralisation. Study Design: A sample of 416 children aged 6–14 years with MIH or MH was identified from a specialist paediatric dental practice in Melbourne, Australia. Methods: A questionnaire regarding perinatal and medical histories was sent to their parents/guardians; 182 (44%) useable questionnaires were returned and the dental records of these children were reviewed. Results: The 182 dentitions were distributed as: MIH: 104; MH: 65; MIH* (permanent incisors unerupted): 13. These dentitions contained 720 FPMs; 429 FPMs were hypomineralised, distributed as: MIH: 282 FPMs; MH: 124 FPMs; MIH*: 23 FPMs. The 282 affected FPMs occurred in dentitions with MIH as: 1 FPM: 27%; 2 FPMs: 15%; 3 FPMs: 17%; 4 FPMs: 40% (mean 2.7 ± 1.3 FPMs/dentition). The 124 affected FPMs occurred in dentitions with MH as: 1 FPM: 49%; 2 FPMs: 28%; 3 FPMs: 6%; 4 FPMs: 17% (mean 1.9 ± 1.1 FPMs/dentition). The distribution of moderate to severe hypomineralisation in FPMs was: MIH: 89%; MH: 73%. Affected FPMs were similarly distributed between gender, quadrants and arches. At least one condition putatively associated with MIH/MH was seen in histories of 166 children (91 %); ear infections, fevers, and perinatal conditions occurred in 53–66% of children. Frequent condition combinations were: ear infections + fevers (40% of children); antibiotics + ear infections (54%); antibiotics + other illnesses (56%). Conclusions: All four FPMs in a given dentition were more likely to be affected and to differing extents in MIH than in MH. Putative associations appear to exist between MIH/ MH and combinations of antibiotic use, ear infections, fevers, perinatal conditions, and other illnesses in the child’s first 3 years. It is proposed that MIH is a more severe form of the hypomineralisation condition than MH, forming an MIH spectrum.

Splinting duration and periodontal outcomes for replanted avulsed teeth: a systematic review

Clinical guidelines are now available for the management of avulsed teeth. The principles of evidence-based dentistry can be used to assess whether these guidelines are based on currently-available evidence. A qualitative systematic review was conducted of relevant clinical literature to examine the evidence on splinting duration and periodontal healing outcomes. The review was constrained markedly by small sample sizes, retrospective nature of clinical audits, dissimilarities of selected studies in their design, methodology and observation periods, and lack of uniformity in terminology for outcomes. A total of 138 replanted avulsed permanent teeth pooled from four papers each reporting both short-term splinting (14 days or less) and long-term splinting (over 14 days) in accord with current clinical guidelines, were studied. The evidence for an association between short-term splinting and an increased likelihood of functional periodontal healing, acceptable healing, or decreased development of replacement resorption, appears inconclusive. The study found no evidence to contraindicate the current guidelines and suggests that the likelihood of successful periodontal healing after replantation is unaffected by splinting duration. Pending future research to the contrary, it is recommended that dentists continue to use the currently-recommended splinting periods when replanting avulsed permanent teeth.

An evidence‐based assessment of the clinical guidelines for replanted avulsed teeth. Part I: timing of pulp extirpation

BACKGROUND Clinical guidelines for the management of avulsed teeth recommend pulp extirpation (PE) within 10 to 14 days of replantation. The principles of evidence-based dentistry can be used to assess whether this is the best approach based on currently-available evidence. The objective of this study was to use the principles of evidence-based dentistry to answer the PICO Question: (P) For a replanted avulsed permanent tooth, (I) is early PE within 10 to 14 days of replantation, (C) compared with delayed pulp extirpation, (O) associated with an increased likelihood of successful periodontal healing after tooth replantation? MATERIALS AND METHODS A literature search was performed across four internet databases for relevant citations (n = 38,400). Limiting citations to those in English and removing duplicates produced a set of titles (n = 14,729) which were sieved. Relevant titles were selected for abstract assessment (n = 628), and then papers were selected for examination (n = 84). Inclusion criteria were applied and six papers (total 236 teeth) met the final criteria for meta-analysis. RESULTS Meta-analyses found a statistically significant association between PE performed after 14 days and the development of inflammatory resorption [common odds ratio (COR) = 0.37, standard error (se) = 0.50, 95% confidence interval (CI): 0.14-0.98]. Pulp extirpation within 10 days of replantation was not significantly associated with a decreased likelihood of developing inflammatory resorption. There were no statistically significant differences in PE times for functional healing, acceptable healing without progressive resorption, or the development of replacement resorption. CONCLUSION There is clinical evidence for an association between PE performed after 14 days following replantation and the development of inflammatory resorption. This investigation supports the current clinical guidelines for PE within 10 to 14 days of replantation.

An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part II: prescription of systemic antibiotics.

BACKGROUND Current clinical guidelines recommend prescribing systemic antibiotic therapy (SAT) for patients having an avulsed permanent tooth replanted. The principles of evidence-based dentistry can be used to assess whether this is the best approach based on currently-available evidence. The objective of this study was to use the principles of evidence-based dentistry to answer the PICO question: (P) for a replanted avulsed permanent tooth, (I) is prescribing SAT, (C) compared with not prescribing SAT, (O) associated with an increased likelihood of successful periodontal healing after tooth replantation? MATERIALS AND METHODS A literature search was performed across four internet databases (Ovid Medline, Cochrane Library, PubMed, ISI Web of Science), for relevant citations (n = 35 702). Limiting citations to those in English and removing duplicates produced a set of titles (n = 14 742) that were sieved according to evidence-based dentistry principles. Relevant titles were selected for abstract assessment (n = 782), identifying papers for examination (n = 74). Inclusion criteria were applied and three papers (326 total teeth) met the final criteria for meta-analysis. RESULTS Meta-analyses found no statistically significant difference between prescribing or not prescribing antibiotics for acceptable periodontal healing without progressive root resorption (common odds ratio = 0.90, SE = 0.29, 95% confidence intervals = 0.51-1.58). CONCLUSION The evidence for an association between prescribing SAT and an increased likelihood of acceptable periodontal healing outcome is inconclusive. This investigation of antibiotic use as defined in the clinical guidelines indicates there is inconclusive clinical evidence from studies of replanted avulsed human teeth to either contradict or support the guideline. Pending future research to the contrary, dentists are recommended to follow current guidelines in prescribing SAT when replanting avulsed teeth.

Intake of sweet drinks and sweet treats versus reported and observed caries experience

AIM: This was to study the intakes of sweet drinks and sweet treats of children and their caries risk using the Paediatric Risk Assessment Tool (PRAT, 2003) and Caries-risk Assessment Tool (CAT, 2007–8). STUDY DESIGN: Parents of 266 healthy primary school children completed the PRAT questionnaire during their child’s dental appointment at the Royal Dental Hospital of Melbourne, Australia, describing their fluid and sweet treat intakes in the past 24 hours, oral hygiene practices and past caries. A subgroup (n=100) was examined clinically (CAT) for caries requiring restoration, visible plaque, gingivitis, orthodontic appliances, enamel defects, and use of dental care. RESULTS: The estimated mean daily fluid intake was 1.5±0.5L; fluids were consumed 3–5/day by 57% of children and 78% usually had evening/night drinks. Fluids consumed were: tap water by 90%, milk by 74%, juice by 50%, regular soft drink by 30%; sweet treats were consumed by 62% and confectionery by 25%. Most children (69%) brushed their teeth ≥2/day; 5% flossed daily. Parentally-reported caries was associated significantly with increasing treats frequency (p=0.006). In the subgroup, 81% were at high caries risk; 47% had irregular dental care; 21% had sweet drinks/foods frequently between meals; 49% had visible plaque/gingivitis, and 34% had enamel demineralisation. Caries observed in the past 12 months was associated significantly with evening sweet drinks (p=0.004), and suboptimal fluoride exposure (p=0.009). Caries observed in the past 24 months was associated significantly with treats frequency (p=0.006), intake of sweet drinks plus treats (p=0.000), enamel demineralisation (p=0.000) and irregular dental care (p=0.000). CONCLUSIONS: The PRAT and CAT are valuable tools in assessing children’s caries risk. The risk of caries from frequent intake of sweet drinks, either alone or in addition to sweet treats, must be emphasised to parents. All parents, and particularly those of children assessed at high risk from intakes of sweet drinks and sweet treats, suboptimal fluoride exposure, or enamel demineralisation, must be encouraged to obtain regular dental care for their children.

Clinical studies on molar-incisor-hypomineralisation part 2: development of a severity index.

Aim: This was to examine the records of 182 children (aged 6–14 years) with molar-incisor-hypomineralisation (MIH) or molar hypomineralisation (MH) in order to develop and examine a Hypomineralisation Severity Index for first permanent molars (FPMs). Study Design: Records of 429 FPMs in these children were examined and scored for eruption status, extent of hypomineralisation, sensitivity, number of restorative treatments; summed scores were converted to an index for each dentition (possible range: 1.25–7.00). Indices were examined regarding medical conditions occurring singly or in combinations in parentally-recalled children’s histories to age 3 years; mean indices were compared for dentitions with these conditions/combinations. Results: The proportion of FPMs receiving no/preventive treatment was higher in dentitions with MH than with MIH (56% vs. 41%); restorative treatment for FPMs was more frequent in dentitions with MIH than with MH (45% vs. 29%). Dentitions with MIH had higher severity indices than those with MH (MIH: index range: 3.25–5.25: 43%; MIH: index range: 1.25–2.00: 61 %). Mean severity indices clearly had a higher trend in dentitions of children with certain condition combinations than for those without. Ten condition combinations each contained 3 to 5 medical conditions; 11/12 condition combinations included fevers; 9/12 included chicken pox; 9/12 included perinatal conditions, 6/12 included antibiotic use. Conclusions: A preliminary Hypomineralisation Severity Index developed for dentitions with hypomineralised first permanent molars in children has shown that MIH and MH form part of an MIH spectrum, where MIH is a more severe form of the condition than MH. The index has indicated associations between hypomineralisation of these molars and combinations of medical conditions, particularly implicating fevers, chicken pox, perinatal conditions and antibiotic use. Further clinical studies are indicated to validate the proposed index and confirm its prognostic value in treatment planning.

Distribution and severity of molar hypomineralisation: trial of a new severity index

BACKGROUND Current molar hypomineralisation (MH) indices do not guide clinicians in management of affected dentitions, and treatment is based on individual judgment. AIM The aims of this study were to describe characteristics of MH and molar incisor hypomineralisation (MIH) and trial the new Molar Hypomineralisation Severity Index (MHSI). DESIGN First permanent molars (FPMs) and permanent incisors (PIs) in 283 affected children were examined for hypomineralisation characteristics [defect colour, location, post-eruptive breakdown (PEB); restorations placed/replaced/atypical; sensitivity]. The MHSI scores were compared with treatment received (152 children). RESULTS Mean (SD) affected teeth/dentition were as follows: FPMs: 3.2 (1.0) and PIs: 1.6 (1.6). Affected FPMs showed no arch or quadrant predilection; maxillary central PIs were affected particularly. As affected FPMs/dentition increased, MIH diagnoses also increased (P = 0.009). Among FPMs, defects most prevalent were brown (47%) and cuspal (74%); 67% showed PEB. Before study entry, 43% of FPMs had restorations placed/replaced. Among PIs, white defects were common (65%) on smooth surfaces; sensitivity was rare. Affected FPMs received more restorations and extractions than unaffected FPMs (P = 0.0001). As MHSI scores increased, FPM treatments/dentition increased (number, invasiveness). All characteristics were significant in predicting treatment (logistic regression model). CONCLUSIONS A spectrum from MH to MIH occurred. The MHSI characteristics were predictive of the treatment of affected FPMs and can guide management.

An in vitro Comparison of Detection Methods for Approximal Carious Lesions in Primary Molars

Background/Aims: This study aimed to compare and contrast in vitro six methods to determine the most accurate method for detecting approximal carious lesions in primary molars. Methods: Extracted primary molars (n = 140) were stored in 0.02% chlorhexidine solution and mounted in light-cured resin in pairs. The six carious lesion detection methods used by the three examiners to assess approximal carious lesions were visual inspection, digital radiography, two transillumination lights (SDI and NSK), and two laser fluorescence instruments (CDD and DDP). Five damaged teeth were discarded. The teeth (n = 135) were sectioned, serially ground, and examined under light microscopy using Downer’s histological (HST) criteria as the gold standard. Intra- and inter-examiner reliability, agreement with HST, specificity, sensitivity, receiver operating characteristic (ROC) curves, and areas under the curve were calculated. Results: This study found visual inspection to be the most accurate method when validated by histology. Transillumination with NSK light had the highest specificity, and digital radiography had the highest sensitivity for detecting enamel and/or dentinal carious lesions. Combining specificity and sensitivity into the area under ROC curves, enamel plus dentinal lesions were detected most accurately by visual inspection followed by digital radiography; dentinal lesions were detected most accurately by digital radiography followed by visual inspection. Conclusions: None of the four newly developed methods can be recommended as suitable replacements for visual inspection and digital radiography in detecting carious lesions on approximal surfaces of primary molars, and further developmental work is needed.

Fourier analysis of facial profiles of young twins

Twins studies provide a powerful approach to determining the relative contribution of genetics and environment to observed variation. Such studies assume trait differences in monozygous (MZ) twins are due to environmental factors and those in dizygous (DZ) twins are due to both genetic and environmental factors. This study quantitated facial profiles of twins using Fourier equations, determining their value in profile analysis and the assessment of the genetic contribution to facial shape. Standardized profile slide photographs of 79 pairs of 4-6 year-old twins (37 MZ pairs, 42 DZ pairs) were scanned and x and y coordinates were extracted from each profile using sellion and Campers plane as references. The coordinates were subjected to Fourier analysis and the normalised vertex projection coefficients were studied. The means of the differences between coefficients for MZ co-twins did not differ significantly from that of DZ co-twins, although the DZ group showed higher mean differences in the higher harmonics. Subjective examination of superimposed reconstructions showed wider variation between DZ co-twins than MZ co-twins. Correct classification of twins by discriminant function analysis using Fourier coefficients was similar for both groups (MZ: 70.3%; DZ: 73.8%). Fourier analysis could quantitate facial profiles of young children and differentiate some details, but was unable to discriminate between genetic and environmental influences, and any possible interactions between these influences, on their overall facial profiles at this developmental stage.

Mineral trioxide aggregate as a pulpotomy medicament: A narrative review

SummaryBackground: Several medicaments have been used to devitalize remaining pulp or maintain pulp vitality and promote healing. Based on pulpal biocompatibility and good sealing ability, a growing interest in more biocompatible materials promotes mineral trioxide aggregate (MTA) as an alternative to traditional medicaments. Uniquely, MTA can preserve pulpal health predictably and promote healing with pulp regeneration. Methods: Using electronic search all papers published since 1993 on the use of MTA in paediatric dentistry were identified. This paper provides a narrative review of the current literature on MTA, formocresol, ferric sulphate and calcium hydroxide with particular reference to primary teeth pulpotomy medication. Conclusion: The use of formocresol or formaldehyde-based medicaments should be replaced with more biocompatible medicaments possessing antimicrobial and pulpal regenerative properties. Of the four pulpotomy medicaments discussed, mineral trioxide aggregate is recommended as the medicament of choice.