Monty Duggal

A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study

The aim of this pilot study was to evaluate the clinical efficacy of mineral trioxide aggregate (MTA) as an apexification material when used in non-vital immature permanent incisors in children. Fifteen children with a mean age of 11.7 years and 17 non-vital permanent incisors were ajudged suitable for inclusion. Standard endodontic procedures were followed and an apical plug of 3-4 mm was created by using MTA after a calcium hydroxide intracanal dressing had been applied for at least 1 week. Final obturation was completed by using thermoplastisized Gutta-Percha (Obtura II) at least 1 week following MTA placement. Subjects were reviewed clinically and radiographically at 3-month intervals. Mean follow-up time for MTA was 12.53 months (+/-2.94 SD). Of the total of 17 teeth treated, MTA placement was considered to be adequate in 13 teeth. The procedure showed clinical success in 94.1% of the cases, radiographic success was found to be 76.5% and in further three cases (17.6%) the outcome was considered to be uncertain. This is one of the very few studies that have reported the out coming of MTA as an apexification material in children with non-vital teeth and incomplete root development. However, larger clinical studies are required to evaluate the long-term success of this procedure.

Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1

This is the first of two papers discussing the implications of dental trauma for patients requiring orthodontic treatment. This paper will focus on the factors the orthodontic specialist should consider when contemplating movement of traumatized teeth. The prevalence of dental trauma and the recognition and prevention of traumatic injuries are discussed. The evidence available in the literature relating to orthodontic tooth movement in vital and endodontically treated traumatized teeth is explored. The interdisciplinary management of root fractured and intruded teeth receive special attention. The second paper will look at the role of the specialist team in the management of failing anterior teeth and will outline possible treatment options for children and adolescents encountering such situations. Avulsion injuries and tooth transplantation are considered in particular detail.

The prevalence of molar incisor hypomineralisation in Northern England and its relationship to socioeconomic status and water fluoridation

BACKGROUND Molar incisor hypomineralisation (MIH) is a condition which has significant implications for patients and service provision. AIMS The aim of this survey was to determine the prevalence of MIH in 12-year olds in Northern England and to consider the relationship with socioeconomic status and background water fluoridation. DESIGN Twelve-year-old children were examined for the presence of MIH. Participating dentists were trained and calibrated in the use of the modified Developmental Defects of Enamel index. Children were examined at school under direct vision with the aid of a dental mirror. A diagnosis of MIH was attributed to a child if they had a demarcated defect in one or more of their first permanent molars. RESULTS Of 4795 children that were selected, 3233 (67.4%) were examined. Overall prevalence of MIH was 15.9% (14.5-17.1%). There was an association between prevalence of MIH and deprivation quintiles with a positive correlation in the first 4 quintiles (P < 0.05). There was no difference in prevalence between fluoridated Newcastle and other areas. CONCLUSION Prevalence of MIH is equivalent to other European populations. Prevalence was related to socioeconomic status but not to background water fluoridation.

Interventions for treating traumatized necrotic immature permanent anterior teeth: inducing a calcific barrier & root strengthening.

BACKGROUND Apical barrier formation and root strengthening procedures have been extensively described in the literature. This systematic review attempts to establish where the effects of interventions using multi-visit apexification, single visit apical plug techniques and root strengthening procedures are consistent and where they may vary significantly. OBJECTIVES To evaluate the relative effectiveness of apexification and apical plug techniques as well as root strengthening procedures for treating traumatized necrotic immature permanent anterior teeth through a systematic review of randomized controlled trials. Reported immediate and/or long-term adverse events and effects of the materials and techniques are also evaluated. SEARCH STRATEGY & SELECTION CRITERIA Structured electronic and hand search was performed with no restriction on the language of publication. Only randomized controlled trials comparing different apical barrier formation techniques and root strengthening procedures in traumatized necrotic immature anterior teeth were assessed. RESULTS Two hundred studies were identified but only two were suitable for inclusion. Included studies investigated multi-visit apexification techniques using calcium hydroxide and tricalcium phosphate. There were no eligible studies investigating root strengthening procedures or any other intervention for apical barrier formation in necrotic immature anterior teeth. No reliable information was available on long-term adverse effects of the reported interventions or cost implications. CONCLUSIONS Based on two included studies, there is weak evidence supporting the use of either calcium hydroxide or tricalcium phosphate for apical barrier formation in necrotic immature anterior teeth employing multi-visit apexification techniques. The evidence is insufficient to provide guidelines for practice. There was no reliable evidence on adverse events or long-term effects after the use of calcium hydroxide or tricalcium phosphate justifying caution in their use in apical barrier formation techniques.

Discoloration of Teeth after Avulsion and Replantation: Results from a Multicenter Randomized Controlled Trial

INTRODUCTION There is evidence to suggest that Ledermix, placed as an intervisit root canal dressing, might improve periodontal healing after replantation of avulsed teeth. As a part of a multicenter randomized controlled trial, we aimed to compare the effect of 2 root canal medicaments, Ledermix and Ultracal XS, on the discoloration of replanted teeth. METHODS Discoloration was investigated by using 3 methods: patient satisfaction with the color of replanted teeth, clinical photographs taken at baseline and 12-month reviews, and estimation of color change by using CIELAB scores for baseline and 12-month photographs. RESULTS Twenty-two patients (27 teeth) were recruited. Ten patients (12 teeth) were randomized to the Ledermix group and 12 patients (15 teeth) to the Ultracal XS group. At 12 months, 8 patients were concerned with the discoloration of their teeth. Seven came from the Ledermix group and 1 from the Ultracal XS group. This difference was significant (Fisher exact test, P = .009). Standardized photographs were taken for the patients recruited at one center only (17 patients). There was significant discoloration of teeth from baseline with Ledermix, causing a darkening and gray-brown discoloration (mean change from baseline to 12 months, L∗ = -5.1, a∗ = 0.3, b∗ = -1.2, and ΔE = 8.1) and Ultracal XS, causing a yellowing and lightening of teeth (L∗ = 1.9, a∗ = 0.3, b∗ = 3.3, and ΔE = 5.4). There was a significant difference for the L∗ and b∗ variables (independent t test) between the 2 groups. CONCLUSIONS Both root canal medicaments cause discoloration, with Ledermix proving less acceptable to patients.

Dental trauma: part 2. Managing poor prognosis anterior teeth – treatment options for the subsequent space in a growing patient

Part 1 concentrated on implications of dental trauma especially prior to and during orthodontic treatment. This paper examines the literature supporting various treatment options for poor prognosis anterior teeth and subsequent space generated when these teeth are lost. The role of an interdisciplinary team in managing this clinical situation is essential to obtain optimal results and an orthodontist is an essential member. Although some treatment options are not provided by orthodontists it is important that they have some knowledge of these and the latest research that support their use. Other techniques lie very much within the orthodontic remit. Treatment options can be split into maintaining the failing tooth or extraction and restoration of the edentulous gap. This paper reviews various treatment options including periodontal regeneration, surgical repositioning and distraction osteogenesis, composite build up to incisal levels and decoronation when maintaining a failing tooth. When extraction and restoration of edentulous gap is required the following treatment modalities are discussed: extraction technique to retain bone quantity, orthodontic space closure and opening (site development), autotransplantation, partial denture, resin bonded bridge and implants. All these options should be considered and available to an interdisciplinary team to ensure optimal care of children with anterior teeth of poor prognosis.

Pulpotomy in primary teeth: Review of the literature according to standardized assessment criteria

Aim: To assess the relevant literature using a modification of the criteria listed in the introductory paper to this issue [Curzon and Toumba, 2006], and to review several new publications on pulpotomies with different materials and techniques that appeared after previously published reviews. Methods: A search of the relevant literature on pulpotomies was identified through Medline between the years 1966–2005. The search generated a total of 358 citations and sieving of these papers was conducted by examining the paper title and assessing its relevance [Loh et al, 2004]. Only clinical studies (non-specified) and retrospective studies were included for assessment. There were 17 criteria (considered major) weighed 2 points and 8 criteria weighed 1 point. A paper that would score between 38–42 points (90+ %) was assessed as Grade A, a score from 32 to 37 points (75–89%) was Grade B1, and between 25 to 31 points (60–74%) Graded B2. Any other paper that reached 24 points or less (less than 59%) was rated Grade C. Results: Of the 358 papers originally identified 48 clinical trials were evaluated according to the set criteria. There was only one paper grade A, 5 papers graded B1, 3 graded B2 and 39 received a C grade. Formocresol or ferric sulphate medicaments were found to be likely to have similar clinical/radiographic results, and MTA seemed to be a more favourable pulp dressing. Conclusion: No conclusion can be made as to the optimum treatment or technique for pulpally involved primary teeth. More high quality, properly planned prospective studies are necessary to clarify these points.

Histological comparison of pulpal inflammation in primary teeth with occlusal or proximal caries

OBJECTIVE A number of clinical and histological studies have investigated caries-related changes in the primary tooth pulp, but the effect of caries site, as a clinical variable, has not been previously considered. This study sought to compare inflammatory changes within the pulp of primary molars according to the location of the caries lesion (occlusal or proximal). METHODS Eighty-three primary molars were extracted under general anaesthesia for caries and/or orthodontic reasons, and were split immediately after removal and fixed in 10% formalin. Teeth were then decalcified, sectioned, and stained with haematoxylin and eosin for histological examination using light microscopy. Caries depth was measured using a graticle, and the site of the caries lesion noted as occlusal or proximal. Samples were further classified into one of five subgroups according to the observed degree of pulpal inflammation. RESULTS Key findings were that where caries depth was less than 50% of the total dentine thickness, there were no significant differences in inflammatory status according to caries site. In contrast, marked inflammatory changes were significantly more likely throughout the coronal pulp of teeth with proximal caries compared to teeth with occlusal caries where caries depth was equal to, or greater than, 50% of the total dentine thickness (P = 0.017, Fishers exact test). CONCLUSION Primary teeth with proximal carious lesions extending more than 50% through the dentine thickness appear to have more extensive inflammatory pulpal changes than teeth with occlusal caries of a similar depth. This finding has clinical implications and may help inform treatment decisions in the management of primary teeth with deep carious lesions.

Pulpal status of human primary teeth with physiological root resorption

OBJECTIVE The overall aim of this study was to determine whether any changes occur in the pulpal structure of human primary teeth in association with physiological root resorption. METHODS The experimental material comprised 64 sound primary molars, obtained from children requiring routine dental extractions under general anaesthesia. Pulp sections were processed for indirect immunofluorescence using combinations of: (i) protein gene product 9.5 (a general neuronal marker); (ii) leucocyte common antigen CD45 (a general immune cell marker); and (iii) Ulex europaeus I lectin (a marker of vascular endothelium). Image analysis was then used to determine the percentage area of staining for each label within both the pulp horn and mid-coronal region. Following measurement of the greatest degree of root resorption in each sample, teeth were subdivided into three groups: those with physiological resorption involving less than one-third, one-third to two-thirds, and more than two-thirds of their root length. RESULTS Wide variation was evident between different tooth samples with some resorbed teeth showing marked changes in pulpal histology. Decreased innervation density, increased immune cell accumulation, and increased vascularity were evident in some teeth with advanced root resorption. Analysis of pooled data, however, did not reveal any significant differences in mean percentage area of staining for any of these variables according to the three root resorption subgroups (P > 0.05, analysis of variance on transformed data). CONCLUSIONS This investigation has revealed some changes in pulpal status of human primary teeth with physiological root resorption. These were not, however, as profound as one may have anticipated. It is therefore speculated that teeth could retain the potential for sensation, healing, and repair until advanced stages of root resorption.

Effect of Addition of 0.103% Citrate to a Blackcurrant Drink on Plaque pH in vivo

The aim of the present study was to investigate whether the addition of a small amount of citrate to infant fruit drinks resulted in a similar beneficial effect to that reported recently with 10% sucrose solution. A popular blackcurrant drink was tested with and without added 0.103% citrate by measuring its ability to depress plaque pH in 20 adult subjects using the plaque-harvesting technique. Solutions of 10% sucrose and 10% sorbitol were used as positive and negative controls, respectively. The results showed that the blackcurrant drink with added citrate had a significantly weaker plaque pH response as compared with the blackcurrant drink without added citrate and 10% sucrose (positive control). The mean areas enclosed by the pH curve below pH 6.0 (+/- SD) were 10% sorbitol (negative control) 0.00, blackcurrant with 0.103% citrate 1.85 +/- 1.07, plain blackcurrant 4.65 +/- 2.11, and 10% sucrose 6.25 +/- 2.35. The acidogenic potential of the blackcurrant drink with added citrate was less than half as compared with the plain blackcurrant drink. It was concluded that the addition of relatively low levels of citrate to a blackcurrant drink reduces the acidogenic response in plaque.