Reasons for early loss of primary molars

PURPOSE

The aims of this study were to investigate the principal reasons for untimely loss of primary molars and to evaluate the risk factors of early primary molar loss in children aged four to nine years.

MATERIALS AND METHODS

1150 untimely lost primary molars were analyzed from 546 patients. The early loss of primary molars was analyzed in relation to age, sex, dmf (t), DMF (T) scores, toothbrushing frequency, history of treatment and maternal education. The data were converted to SPSS format. Pearson Chi-square test was used for statistical analysis.

RESULTS

Among the investigated subjects, 15.2% of children reported regular toothbrushing. Only 23.1% of subjects had a history of treatment before the tooth extraction and 33% of mothers had a low education level. Untimely loss of primary molars due to pain, caries and sepsis were 30.2%, 31% and 38.8%, respectively. The frequency of 'only one primary molar loss' was significantly higher in group 1 (p < 0.05), however the frequency of 'more than one primary molar loss' for group 2 was more than group 1 (p < 0.05). Irregular toothbrushing for the children in group 2 was found significantly high than in group 1 (p < 0.05). Irregular toothbrushing was associated with number of early primary molar loss in group 2 (p < 0.05). The level of maternal education was associated with dmf (t) scores (p < 0.05). The caries incidence was associated with number of early primary molar loss in both groups (p < 0.05). The mean number of treated teeth before extraction for group 2 was significantly higher than for group 1 (p < 0.05).

CONCLUSION

Results of this study suggested that irregular toothbrushing, high dmf (t) scores and untreatment of carious primary molars were significant risk factors in early loss of primary molars. Every effort must be taken into account in restoring rather than extracting carious teeth.

Combined therapy in the treatment of dens invaginatus: case report

Dens invaginatus is an anomaly that has numerous complex forms. Whenever endodontic therapy involving such a tooth becomes necessary, the clinician must be aware of the various treatments available for proper care. We present a case report of a maxillary lateral incisor having the anomaly in which both nonsurgical and surgical treatment was performed.

Periosteal grafts as barriers in periradicular surgery: report of two cases

AIM

To describe the usefulness of periosteal grafts as barriers for bone regeneration in periradicular surgery when advanced periodontal breakdown occurs.

SUMMARY

The treatment of advanced periodontal breakdown as a result of an associated endodontic lesion constitutes a multifaceted challenge to the clinician. If the source of the irritation cannot be removed by orthograde endodontic treatment, nonsurgical and surgical endodontic/periodontal intervention may be required. Two cases with suppurative chronic apical periodontitis with apicomarginal communication are described. Clinical and radiological evaluations were completed immediately prior to surgery, a week later and every 2 months after surgery for 10 months. Both patients were treated using split-thickness flaps and lateral displacement of the periosteum prior to suturing, in order to close the communication between the oral and the periapical surroundings. A remission of the clinical signs and symptoms, and successful healing in the short-term were achieved in these cases.

KEY LEARNING POINTS

Periapical and periodontal lesions are closely related through pathways of communication. Disruption of the cortical plate and the presence of dentoalveolar sinus tracts can have a deleterious effect on the regeneration process after periradicular surgery. The adoption of supplementary periodontal surgical techniques may help to solve some of the difficulties in the healing process in periradicular surgery. Periosteal grafts have been shown to have the potential to stimulate bone formation when used as a graft material.

Prophylactic root resection and periapical grafting for anterior implant aethetics: an integration of tissue-reconstruction and tissue-preservation concepts

The presence of active infections involving the labial bony plate of a failing maxillary anterior tooth presents a challenging situation for aesthetic implant replacement. Not only would the septic state of an abscess be detrimental for immediate implant placement and bone augmentation, but the accompanying bony destruction would also increase the likelihood and magnitude of gingival recession, making this a bioaesthetic challenge. This article describes a technique that integrates tissue-reconstruction and tissue-preservation concepts to achieve peri-implant tissue aesthetics as well as its clinical rationale.

Periapical Curettage: An Alternative Surgical Approach to Infected Mandibular Cheek Teeth in Horses

OBJECTIVE

To evaluate an alternative surgical method for treating periapical infection of the mandibular cheek teeth of horses.

DESIGN

Retrospective study.

ANIMALS

Eleven horses (3-13 years) with periapical mandibular tooth infection.

METHODS

Hospital records (1992-2002) of horses that had periapical curettage for the treatment of mandibular cheek tooth root infection were retrieved. Clinical signs, radiographic, and surgical reports were reviewed. Outcome was obtained by telephone questionnaire for 7 horses and by physical examination in 2.

RESULTS

Eleven horses (14 infected mandibular molariform teeth) had periapical curettage. Two horses were lost to follow-up. Mean follow-up was 41 months; 2 horses had subsequent tooth repulsion, 7 (78%) horses healed completely although 2 horses still had some local mandibular swelling.

CONCLUSION

Periapical curettage, which allows alveolar drainage, appears to be a viable treatment option for periapical infections of equine mandibular cheek teeth.

CLINICAL RELEVANCE

Periapical curettage can be performed simply, without expensive imaging or surgical equipment, and thus is useful for both referral and first opinion practice.

Endodontic treatment of dens invaginatus type III with three root canals and open apical foramen

AIM

To describe the conservative endodontic treatment and the 1-year follow-up of a permanent maxillary lateral incisor with dens invaginatus.

SUMMARY

Frequently, the root canal treatment of invaginated teeth is challenging because of problems associated with gaining access to the root canals and with variations of canal morphology associated with this type of malformation. The present case describes the complex root canal treatment of dens invaginatus in a maxillary lateral incisor with three root canals (Oehler type III), incomplete apex formation, necrotic pulp and abscess formation. After gaining access to two root canals and the invagination with the help of a dental operating-microscope, the canals and the invagination were instrumented and calcium hydroxide dressing was applied for 6 months. Apexification and osseous bone repair were achieved, and the canals were filled with gutta-percha. A follow-up after 1 year showed that the tooth was free of any clinical symptoms and the periapical condition was normal.

KEY LEARNING POINTS

The present case demonstrated that conservative root canal treatment can be performed successfully even in sever cases of dens invaginatus. The use of a dental operating microscope can help in the management of complicated cases of invaginated teeth through conventional root canal treatment.

Surgical intervention of mucosal fenestration in a maxillary premolar: a case report

Labial mucosal fenestration of the root apex is an uncommon occurrence. An unusual case involving a maxillary right first premolar is described. When presented, the tooth was nonvital with the buccal root apex readily seen through a soft tissue and bone fenestration. Conventional endodontic treatment with gutta percha failed to resolve the problem. Periodontal surgery with a laterally positioned pedicle flap was thus scheduled. At the 1-month recall, complete healing was evident in the surgical site, and the fenestrated area of the maxillary right first premolar was filled with healthy mucosal tissue. One-year postoperatively, the mucosa remained covered, and there was radiographic evidence of bone infilling in the periapical region.

Emergency management of acute apical abscesses in the permanent dentition: a systematic review of the literature

OBJECTIVE

To perform a systematic literature review and meta-analysis on the effectiveness of interventions used in the management of acute apical abscess in the permanent dentition.

METHODS

Electronic databases were searched from their inception to March 2002. These searches, combined with manual searching, yielded 85 citations, of which 35 were relevant. Independent application of inclusion criteria by 3 reviewers yielded 8 eligible randomized controlled studies. Data on population, interventions, outcomes (reduction of pain or swelling or both, as reported by patients or clinicians) and methodological quality were determined by independent triplicate review. Disagreements were resolved by consensus.

RESULTS

All papers included in the meta-analysis compared an antibiotic with an active control, a placebo or no pharmacotherapy as an adjunct for patients who had received concomitant therapy (i.e., incision and drainage, endodontic therapy or extraction). The 8 trials were randomized; in 3 of these, the method of randomization was described and appropriate. Five studies were double-blinded, and 2 of these described the method of blinding. Four trials described withdrawals, but none included an intention-to-treat analysis. Six studies compared 2 antibiotics. For the outcomes "absence of infection"and "absence of pain" the pooled odds ratios (ORs) were not statistically significant; for the outcome "absence of pain and infection," 3 studies showed an equivalent treatment effect in both treatment and control groups. One open-label study (with a quality score of 2) showed a result favouring azithromycin over co-amoxiclav (OR 0.58, 95% confidence interval 0.35-0.96). Two studies compared adjunctive antibiotic therapy with placebo; no benefit to patients was demonstrated with this intervention.

CONCLUSIONS

In the management of localized acute apical abscess in the permanent dentition, the abscess should be drained through a pulpectomy or incision and drainage. This analysis indicated that antibiotics are of no additional benefit. In the event of systemic complications (e.g., fever, lymphadenopathy or cellulitis), or for an immunocompromised patient, antibiotics may be prescribed in addition to drainage of the tooth.

[Root growth after wisdom tooth transposition. Case documentation with proposal for a radiologic method to quantify growth]

OBJECTIVES

To introduce a method for assessment of root growth on panoramic radiographs exemplified by a case report on an autotransplanted lower third molar.

MATERIAL AND METHODS

A lower left third molar (T) with incomplete root formation was transplanted for replacement of the lower left first molar in an 18-year-old woman. T was monitored clinically and, together with its neighboring lower second molar (37) with constant root length, also radiographically by means of two panoramic radiographs (OPGs) produced 12 days and 20 months postoperatively. A method for calculation of the root length as a multiple of the crown length is introduced, using accurately reproducible landmarks defining the coronal and apical endpoints of the examined tooth in all OPGs of the series. This method minimizes error due to different magnifications within the set of radiographs.

RESULTS

Using the method introduced, the root length of the constant tooth 37 varied at 2.7% within the set of OPGs, whereas it revealed a 5.6% variation when the evaluation was based on direct measurement. Based on the described method, T revealed a postoperative root growth of approximately one-third of its final length and showed clinically no pathological findings during the observation period.

CONCLUSIONS

Our results indicate that with the described method root growth assessment on panoramic radiographs is more accurate than with direct measurement.

[Brain abscesses after extracranial infections of the head and neck area]

The authors report on 20 immunocompetent patients with brain abscess after 12 cases of middle ear, seven tooth and a single frontal sinus infection. The clinical aspects, hematochemical and microbiological data, the role of imaging diagnostics (CT, MR) and the type of treatment are analysed. Neurosurgery was performed on 17 patients (85%), eight of whom subsequently underwent evacuation of the primary source of infection (four mastoidectomies, two timpanoplasties, two tooth extractions). Mastoidectomy was eventually carried out on one of the three patients who did not undergo neurosurgery. Microbiological diagnosis was possible in nine patients through culture examination: Proteus mirabilis in three cases, Peptostreptococcus sp. in two, Micrococcus varians, Proteus vulgaris, Streptococcus sanguis and Streptococcus viridans not typed in single cases. The pus was sterile in eight patients (47.1% of those operated). An association of two antimicrobial agents was used in 18 patients, while in two cases monotherapy was preferred, based on the isolated bacteria. Treatment lasted on average 38 days. The most frequently used therapy regimen (75%) was the association of a beta-lactam drug with chloramphenicol or metronidazole. Therapy was successful in 19/20 patients; one patient died. There was no significant difference in prognostic terms with regard to sex, age, duration of symptoms prior to diagnosis, clinical picture at onset, number and size of abscesses or type of treatment. Recognising the first clinical signs and symptoms (headache, fever, alterations in consciousness, focal neurological deficit, epileptic seizures) is extremely important for prompt diagnosis of brain abscess.

Trephination for acute pain management

Surgical trephination can and does provide immediate relief of pain, surgical drainage of the infection and related fluids, and in most cases does not require supplementary administration of antibiotics and only minimal amounts of analgesics. This paper outlines the diagnosis and technique of surgical trephination.

Treatment of combined endodontic-periodontic lesions by intentional replantation and application of hydroxyapatites

A case of combined endodontic-periodontic lesions on a mandibular first molar was treated by intentional replantation and application of hydroxyapatites. Four months after the surgery, a porcelain-mental full crown restoration was completed. The 15-month follow-up examination showed that the tooth was clinically and radiographically healthy and functioned well.

Immediate implant in fresh extraction socket of resected mandibular first molar: a preliminary clinical report

This study presents a new technique that involves resection of the affected mesial root in a lower mandibular molar with immediate implant placement in its extraction socket. This technique offers a treatment option for mandibular molars affected by local periapical infection, bifurcation involvement, or buccolingual fractures. Extraction of such molars usually creates a large edentulous span and subsequent restorative problems. The patient is provided with a crown that is supported by an implant in the resected mesial root site and the retained distal root. The crown is esthetic and functional and easy to maintain. This technique was successfully applied on five patients.

SEM observations of resected root canal ends following apicoectomy

The purpose of this study was to examine the apical foramen of root apices extracted during apicotomies. A total of 25 teeth extracted from 25 patients admitted to the Department of Conservative Dentistry at Tokyo Dental College's Chiba Hospital were used for the study. All patients were between 22 to 56 years of age at the time of the study, and each of the 25 cases was determined clinically on radiographs to be chronic apical suppurative periodontitis. Microsurgery was performed on all cases, and the extracted root apices were then observed using SEM. The results demonstrated a wide opening, greater than 350 microns as measured along the major axis, of the apical foramen in 80% of the cases. Various characteristics indicative of resorption were observed around the apical foramen. These features included those believed to have been caused by overinstrumentation during root canal treatment as well as irregularly shaped areas presumed to be apical lesions that had enlarged and eroded. We observed a high frequency of manifestations of cementum resorption surrounding the root apices of teeth with apical lesions. Furthermore, we concluded that in the majority of cases in the present study, due to the fact that the apical foramen exceeded normal opening dimensions as a result of overinstrumentation during root canal treatment or resorption around the root apex, prolongation of the lesions had occurred in response to direct contact of microbial infectious matter and tissues surrounding the root apex over a large area. The above finding suggested that, in cases in which the apical foramen is destroyed through overinstrumentation larger than #35 or in which the apical foramen opens up to dimensions greater than 350 microns due to pathologic resorption, surgical intervention may be indicated. On the other hand, in 64% of the cases, an accessory canal was observed in the root apical lesion. Based on this observation, the presence of an accessory canal in the root apex may contribute to some degree to the prolongation of the lesion.

Pott's puffy tumor and epidural abscess arising from dental sepsis: a case report

OBJECTIVE

To present an unusual case of two uncommon cranial complications of frontal sinusitis: Pott's puffy tumor and epidural abscess arising from frontal sinusitis of dental origin, and also two systemic complications of sinusitis: septicemia and empyema, all occurring in an immunocompetent patient.

STUDY DESIGN

A 21-year-old man presented with a scalp swelling and epidural abscess. Magnetic resonance imaging and computed tomographic scans revealed unilateral opacification of the frontal sinus and an epidural abscess with a direct connection to the scalp abscess. Further history revealed that his symptoms occurred coincidentally with a tooth extraction 2 months before, and he was hospitalized soon after the tooth extraction for sepsis and a lung abscess.

METHODS

A combined neurosurgical and otolaryngologic approach was required to treat the sinusitis and the associated epidural and scalp abscess.

RESULTS

Cultures returned as Streptococcus intermedius from all three sites. The patient was free of disease at the 3-month follow-up.

CONCLUSIONS

Odontogenic maxillary sinusitis is well documented; however, there is little reported of frontal sinusitis arising from dental disease. The prevalence of sinusitis of dental origin will be reviewed, including the microbiology of this particularly virulent organism that persisted despite earlier treatment with ampicillin. Also, the current thoughts on management of these cases will be discussed with particular reference to local therapy for sinusitis in addition to systemic treatment with antibiotics.

Periapical abscess formation and resolution adjacent to dental implants: a clinical report

The vitality of teeth adjacent to dental implants should be considered in the treatment planning of dental implants. Both the restorability of an endodontically treated tooth and the risk of infection of the adjacent implant are important factors in planning for success. Given the illustrated difficulties and difficulties associated with resolving periapical infections of teeth and implants, it is essential to define the vitality of teeth by careful pulp testing and to consider the integrity of existing questionable, endodontically treated teeth before implant treatment. The risk of periapical infection at teeth adjacent to implants must be minimized.

Calcium hydroxide in endodontic retreatment after two nonsurgical and two surgical failures: report of a case

AIM

To describe the role of calcium hydroxide in infection control during complex endodontic retreatment.

SUMMARY

A case is presented in which two conventional endodontic treatments and two surgical interventions failed to bring periapical healing. Despite this history, a further conventional treatment augmented by long-term disinfection with calcium hydroxide finally delivered a successful outcome.

KEY LEARNING POINTS

Periapical healing follows proper intracanal infection control. Despite repeated surgical and nonsurgical intervention, careful retreatment can often bring healing. Calcium hydroxide has long-acting antimicrobial and soft-tissue dissolving activity. It is a helpful adjunct in endodontic retreatment.