Opinions of UK General Dental Practitioners on the Restoration of Posterior Root Filled Teeth: a Vignette Survey

OBJECTIVE

To investigate factors which influence UK general dental practitioners (GDPs) when restoring posterior root filled teeth.

METHOD

An electronic survey was designed to explore current strategies of treatment of posterior root filled teeth by UK-based GDPs working in primary care. Three vignette cases included in the questionnaire explored a variety of tooth, patient, and financial factors. The survey was distributed by email and social media platforms between December 2018 and February 2019.

RESULTS

A total of 528 valid responses were collected. The majority of participants (84.1%) regularly restored posterior root filled teeth with an indirect restoration. Presence of persistent symptoms post root canal treatment (RCT) completion would impact the management of 85% of the surveyed respondents. Referral to a specialist, deferral of provision of the definitive restoration, and fear of litigation were reported by the GDPs as influencing factors.

CONCLUSION

This survey highlights that decision making regarding restoration of root filled teeth is a multifactorial process. Tooth, patient, and financial factors were all shown to influence the restorative management of the posterior root filled teeth.

IS EXTERNAL CERVICAL RESORPTION AN ESTABLISHED MANIFESTATION OF SYSTEMIC SCLEROSIS? A CASE REPORT

AIM

Scleroderma, or systemic sclerosis, is a multisystem autoimmune disorder characterized by hardening and fibrosis of the skin. To date, only a small number of case reports have established a relationship between scleroderma and external cervical resorption (ECR). The aim of this case report is to document the case of a patient with multiple external cervical resorption lesions, who was referred to our unit.

SUMMARY

A 54-year-old female patient, with a 10-year history of systemic sclerosis diagnosed by her rheumatologist, was referred to our unit regarding extensive ECR. A total of 14 maxillary and mandibular teeth with ECR were detected by clinical examination and cone-beam computed tomography (CBCT). The characteristic vascularity of resorptive defects with profuse bleeding upon probing was not evident. The patient declined any active treatment owing to the desire to avoid lengthy and unpredictable treatment, which may hasten the loss of her teeth.

CONCLUSIONS

General practitioners should be aware of the relationship between connective tissue disorders and ECR. Although not well established in the literature, the vascular changes implicated in scleroderma may stimulate the odontoclastic processes involved in ECR.

Management of traumatic dental injuries: a survey of paediatric emergency department health professionals

OBJECTIVE

To assess paediatric emergency department (PED) health professionals' confidence, experience and awareness in managing traumatic dental injuries (TDIs).

DESIGN

A cross-sectional online survey.

SETTING

PED at Alder Hey Children's Hospital and Birmingham Children's Hospital.

RESULTS

94 ED health professionals responded. One-third of responders (n=26) encounter children with dental trauma daily or weekly. TDI teaching during undergraduate training was received by 13% (n=12) of responders, and 32% (n=30) had never received training. Responders thought they would benefit from online resources and regular teaching on paediatric TDIs, in addition to an easy-to-use decision-making tool to signpost families.ED health professionals' confidence in giving advice to families following a TDI, and in recognising types of TDIs, was notably low; -79 and -76 Net Promotor Score, respectively.Responders' awareness of how to recognise and manage TDIs was varied. Majority were aware of the need to attempt to reimplant an avulsed permanent tooth, and the need to refer a child presenting with a complex permanent tooth injury to the oncall dentist. However, very few responders commented on the importance of follow-up. Responders also raised concerns about the lack of dental services to treat TDIs in children.

CONCLUSIONS

There is a need to enhance dental trauma teaching for all ED health professionals who encounter TDIs to increase their confidence and enable them to triage and advise patients appropriately. Additionally, increased signposting for families to the appropriate service could in turn improve outcomes and experience for children who experience a TDI.

Which endodontic access cavity is best? A literature review

The preparation of an access cavity is the first part of endodontic treatment and is a key stage in the healing of both periapical and pulpal infections. It should allow endodontists to remove obstructions in the pulp chamber, locate all canal orifices and clean the entire root canal system with minimum coronal tooth structure removed. This has been done traditionally through establishing straight line access. The development of minimally invasive endodontics aimed to preserve as much of the natural tooth structure as possible, particularly dentine, while undertaking root canal treatment, resulting in the development of other access cavity preparations. This includes conservative, ultra conservative (ninja), truss, guided access, caries-orientated and restorative access cavities. These access cavity preparations also gained popularity due to increased magnification and enhanced lighting, allowing practitioners to visualise the pulpal space in greater detail throughout treatment.Our current recommendation is to conduct access cavities traditionally rather than conservatively. Ideally, conservative access cavities need magnification, which might not be available for all clinicians. With traditional access cavity, the procedure takes less time and it is more predictable to locate the canal orifices, deliver irrigation effectively, avoid iatrogenic damage with biomechanical preparation and achieve better obturation.

Suspected Endodontic Failure in a Patient with Cleidocranial Dysplasia: A Case Report

A patient's medical history and related dental manifestations can significantly contribute to confounding signs and symptoms leading to a diagnostic challenge. An 18-year-old female patient presented with persistent radiographic radiolucency associated with the apex of a previously treated tooth (tooth 9); asymptomatic apical periodontitis and endodontic failure were suspected. This report presents how a patient's condition of cleidocranial dysplasia had a profound effect on her dental history, which included the presence of multiple supernumerary teeth. Extensive surgical intervention during the patient's childhood was required to remove the supernumerary teeth, which resulted in an endodontic misdiagnosis in her adult life. After clinical and radiographic examination, the patient was diagnosed with a periapical scar. Periapical fibrous scars have a prevalence of between 2.5% and 12% and are a rare healing process with fibrous tissue after surgical and nonsurgical interventions. This report describes the diagnosis and pathophysiology of fibrous scars, including their risk factors and long-term monitoring approaches.

The epidemiology of endodontic complexity in general dental practice: a prevalence study

Aim To determine the prevalence and the epidemiology of the factors influencing endodontic complexities in general dental practice.Method Eligible cases where endodontic treatment was indicated as a treatment option were collected by a total of 30 general dental practitioners based in the UK. Online-based Endodontic Complexity Assessment Tool (E-CAT) was used to determine the perceived complexity of each case. In total, 22 categories, including patient- and tooth-related factors, were recorded.Results Collectively, 435 non-surgical root canal treatment cases were assessed. Overall, 72% of the root canal treatments encountered in general dental practice were found to be either uncomplicated (Class I) or moderately complicated (Class II) and can be considered within the remit of general dental practitioners. Despite the relatively equal distribution of the assessed teeth, the proportion of extraction as a proposed treatment for posterior teeth was more than double that of anterior teeth.Conclusion The results obtained in this study provide a good resource and databank for researchers, educators, public health commissioners and academic institutions to access a wide range of information concerning the prevalence and distribution of endodontic complexity.

Electrical stimulation to clinically identify position of the lingual nerve: results of 50 subjects with reliability and correlation with MRI

PURPOSE

Recently we described mapping of the lingual nerve clinically in patients using electrical nerve stimulation. This paper reports results of a larger study with inter- and intra-observer reliability and comparison with positional measurements from magnetic resonance imaging (MRI).

METHODS

In 50 healthy participants, measurements were taken when subjects felt a tingling sensation in the tongue induced by a stimulation probe over the lingual nerve. Three positions were measured in relation to the third molar. Measurement reliability was tested for both inter-observer and intra-observer agreement and positional data of the lingual nerve measured clinically was also compared with nerve position as measured from MRI scans.

RESULTS

Out of 50 participants, 96 nerves (49 = left/47 = right) were included in the study. The lingual nerve was identified in 90% (87) of this sample. The mean of height of the nerve in points A, B and C were 9.64 mm, 10.77 mm and 12.34 respectively. Inter-and intra-observer agreement was considered to be good to excellent (ICC = 0.8-0.96). Agreement between nerve mapping measured values and MRI measured values was good (ICC < 0.6).

CONCLUSION

This technique may prove useful for the clinical determination of lingual nerve position prior to procedures in the third molar region.

Molar-incisor hypomineralisation combat: exploratory qualitative interviews with general dental practitioners in England regarding the management of children with molar-incisor hypomineralisation

Introduction Molar-incisor hypomineralisation (MIH) presents as a spectrum, with severe cases becoming increasingly complex to manage. This study aimed to investigate the perceptions and experience of general dental practitioners (GDPs) in England when managing children with MIH.Method Semi-structured telephone interviews with GDPs who regularly treat children took place in May 2020. A sample of four male and six female GDPs with 1-15 years of experience was achieved through purposively sampling interested parties following advertisement via professional groups. Thematic analysis using a realist and inductive approach was used in analysis.Results The overarching theme was of managing uncertainty, with four subthemes: setting the scene; fighting the tooth; working within the system; and self and interpersonal insight. Despite being knowledgeable, participants expressed varying levels of confidence in many aspects while managing children with MIH. There was a great deal of uncertainty surrounding 'doing the right thing' across the themes. Systemic barriers to managing children with MIH within the general dental service were identified.Conclusion The challenges of managing children with MIH was experienced as 'uncertainty'. Barriers within the general dental service made managing children with MIH difficult and participants relied on colleagues in secondary care to manage severe cases.

Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP): a feasibility study

BACKGROUND

Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology's (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice.

METHOD

This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis.

DISCUSSION

The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN17973604 . Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021.

The transitional care pathway following traumatic dental injuries: Patient perspectives

BACKGROUND AND AIM

The nature of complex traumatic dental injuries (TDIs) often means that management continues through paediatric to adult dental services. Evidence suggests that failure in transitional care can have detrimental impacts on health. There is limited evidence regarding patients' experiences of transitional care pathways (TCPs) in dentistry. The aim of this study was to investigate the views and experiences of the TCP from paediatric to adult care for individuals who have experienced TDIs.

MATERIALS AND METHODS

Semi-structured interviews were undertaken. Ethical approval was granted by the Health Research Authority and sponsored by the University of Liverpool. Inclusion criteria included individuals aged 16 to 21 years old who had received care in both paediatric and adult restorative dentistry departments at Liverpool University Dental Hospital following a TDI. Five purposively sampled patients were interviewed. Thematic analysis was undertaken using NVivo.

RESULTS

Thematic analysis identified 5 main themes with regard to transitional care experience: patient-clinician communication, impact of dental trauma, feelings of uncertainty, patient personal development and transitional care planning. Feelings of uncertainty with regard to the long-term prognosis of traumatized teeth were highlighted. Clear communication and involvement of young people in decision-making was identified as a vital factor to facilitate a successful TCP experience.

CONCLUSION

The involvement of young people in decision-making is essential for a successful TCP. Consideration should be given to development of TCP guidance, to allow for the provision of timely and consistent information regarding the process. Despite this, there needs to be adaptivity within the TCP to create a successful TCP for every young person.

An investigation of transitional care pathways for young people following traumatic dental injuries

Introduction Traumatic dental injuries (TDIs) can cause severe and complex dento-alveolar problems. Management of TDIs frequently extends into adulthood; therefore, a clear transitional care pathway (TCP) is important. Failure of this can prevent engagement in adult dental services and negatively influence treatment outcomes.Aims To assess the availability of TCPs from paediatric and adult specialist care for young people with TDIs.Materials and methods An anonymous, postal survey was designed and administered to all UK specialists in paediatric dentistry registered with the General Dental Council. Quantitative and qualitative data were gathered.Results The response rate was 58% (n = 130). Fifty-five percent (n = 72) stated that there was a dental trauma clinic for children within their locality, while only 22% (n = 29) stated that there was a dental trauma clinic for adults. Sixty-nine percent (n = 90) stated that there was no clear TCP within their locality and 41% (n = 37) of these highlighted a need for a TCP. Thematic analysis of opinions with regards to need for a TCP identified three main themes: pathway availability, access to resources and clinician experience. Following a course of treatment for a patient aged 12 years or above, 24% (n = 31) refer to specialist adult services, with 43% (n = 95) continuing to provide follow-up within paediatric dentistry.Conclusion Follow-up arrangements for young people with TDIs differ across the UK, with inconsistent availability of TCPs. Informal pathways involving referral to multidisciplinary teams may be utilised for follow-up care. Development of a TCP may aid in developing a consistent approach to long-term management of TDIs.

Management of molar-incisor hypomineralisation by general dental practitioners - part two: treatment

Introduction Molar-incisor hypomineralisation (MIH) is a common occurrence in primary and secondary care settings. While severe cases may need specialist care, mild cases should be managed in primary care.Aims To assess how UK-based general dental practitioners (GDPs) plan treatment for children with MIH using two clinical vignettesDesign An electronic vignette survey was designed using clinical photographs and radiographs. Vignette one presented a child with mild MIH who was unhappy about the appearance of his teeth. Vignette two presented an anxious child with severe MIH, caries and sensitivity. Further questions relating to confidence in management of MIH and referral were included. Participants were UK-based GDPs who regularly treat children. The survey was distributed by email and across social media platforms. Data collection occurred between February and May 2019.Results Fifty-eight GDPs completed the survey. Around half of participants addressed the aesthetic concerns of the child in vignette one. The majority of participants demonstrated sound treatment planning in terms of preventive care and management of molars. More GDPs identified increased caries risk in vignette two.Conclusion These findings demonstrate most GDPs in this study were working as effective tier one and two providers when faced with management of children with MIH.

Management of molar-incisor hypomineralisation by general dental practitioners - part one: diagnosis

Introduction Molar-incisor hypomineralisation (MIH) affects one in six children in the UK. For the majority of patients who have mild MIH, this should be managed in primary care.Aims To assess UK-based general dental practitioners' (GDPs) ability to diagnose MIH when presented with multiple clinical vignettes.Design An electronic vignette survey was designed with use of clinical photographs - six cases had MIH and/or hypomineralised second primary molars (HSPMs) (seven possible diagnoses). Four control cases showing caries, fluorosis, amelogenesis imperfecta and dentinogenesis imperfecta were also included. Participants were UK-based GDPs. The survey was distributed by email and across social media platforms. Data collection occurred between February and May 2019.Results Seventy-six GDPs completed the survey; 68.4% (n = 52) of participants were female and 83% (n = 63) of participants graduated after the year 2000. The number of accurate diagnoses for each case were as follows - mild MIH (molars/incisors) 65.79%; mild MIH (molars only) 3.95%; HSPM and MIH (HSPM result) 0%; HSPM and MIH (MIH result) 50%; severe MIH (post-eruptive breakdown) 63.16%; severe MIH (caries) 31.58%; HSPM 3.95%.Conclusion GDPs are able to accurately diagnose MIH best when both incisors and molars are affected and caries is not present.

SARS-CoV-2: characterisation and mitigation of risks associated with aerosol generating procedures in dental practices

Introduction The objectives were to characterise the particle size distribution of aerosols generated by standard dental aerosol generating procedures (AGPs) and to assess the impact of aerosol-management interventions on 'fallow time'. Interventions included combinations of high-volume intraoral suction (HVS[IO]), high-volume extraoral suction (HVS[EO]) and an air cleaning system (ACS).Method A sequence of six AGPs were performed on a phantom head. Real-time aerosol measurements (particle size range 0.0062-9.6 μm) were acquired from six locations within a typical dental treatment room (35 m3).Results The majority (>99%) of AGP particles were <0.3 μm diameter and remained at elevated levels around the dental team during the AGPs. With no active aerosol-management interventions, AGP particles were estimated to remain above the baseline range for up to 30 minutes from the end of the sequence of procedures.Conclusions The results emphasise the importance of personal protection equipment, particularly respiratory protection. Use of HVS(IO), either alone or in combination with the ACS, reduced particle concentrations to baseline levels on completion of AGPs. These data indicate potential to eliminate fallow time. The study was performed using a phantom head so confirmatory studies with patients are required.

The Effects of Different Spectrophotometric Modes on Colour Measurement of Resin Composite and Porcelain Materials

OBJECTIVES

To investigate the influence of a number of controlled modes on the spectrophotometric analysis of the colour of resin composite and porcelain materials.

METHODS

A total of 20 samples of commercially available resin composite, and 20 samples of commercially available porcelain materials in four different shades were produced (five samples for each shade). Colour was measured using a spectrophotometer (CM2600-d, Minolta Konica) set with different colour measuring modes namely, small aperture size (SAV) or large aperture size (MAV); specular component included (SCI), or excluded (SCE); 0% (UV-) or 100% UV illumination (UV+). Colour data were then compared using paired T-test.

RESULTS

Colour coordinates measured with spectrophotometric modes set as 2° observation angle, SAV, SCI, and UV- were significantly different from those measured with 10° observation angle, MAV, SCE, and UV+ respectively in most cases for both materials.

CONCLUSION

Different spectrophotometric modes (2 or 10 degrees observation angle, SAV or MAV aperture size, 0% or 100% UV, and SCI or SCE) significantly influenced the absolute colour measurements of resin composite and porcelain samples.

CLINICAL SIGNIFICANCE

Measuring modes should be taken into consideration when comparing the results of absolute colour measurements of resin composite and dental porcelain materials.

The Effect of Try-In Paste and Resin Cement Shade on Colour Properties of Dental Veneers

OBJECTIVES

The purpose of this study was to investigate how different shades of try-in pastes, uncured and cured resin cements affect the overall colour of porcelain veneer restorations.

METHODS

A total of 90 porcelain veneers of shade Vita 1M1 VM7 and 0.6 mm thick were applied to bovine teeth using 3 shades of resin cement and their try-in paste produced by 3 manufacturers.

RESULTS

Colour differences produced between the try-in pastes and the corresponding shades of cured resin cements ranged from (ΔE* 1.18-3.1). The colour differences between uncured and cured resins of the same shade ranged from (ΔE* 0.78 - 1.41).

CONCLUSIONS

Different shades of try-in pastes and resin cements produced colour changes which are clinically useful in changing the colour of veneer restorations and therefore assist in colour matching to adjacent teeth. Clinically significant differences were noticed between try-in pastes and the cured resin of the same shade, however, there were relatively small changes measured between un-cured and cured resins. The colour match obtained by the try-in paste has to be treated with caution and further evaluation of the restoration made with the resin in place before curing is recommended.

The use of zirconium, single-retainer, resin-bonded bridges in adolescents

This paper presents a series of case reports which demonstrate the replacement of the causes of tooth loss which primarily affect children by the use of all-ceramic resin-bonded bridges.

Assessing the efficacy of denture cleaners with quantitative light-induced fluorescence (QLF)

The aim of this study was to evaluate Quantitative Light Induced Fluorescence (QLF) analysis as a means of determining the ability of denture cleaners to remove stain from denture teeth. This study investigated the appearance of acrylic resin denture teeth subjected to QLF conditions in vitro. It aimed to determine if QLF was an appropriate method for detecting stain and its removal on acrylic resin denture teeth in vitro and also to develop a quantitative and reproducible method for assessing the efficacy of denture cleaners using QLF. This study showed that not all acrylic resin denture teeth fluoresced under QLF examination. QLF demonstrated the ability to detect and quantify longitudinal changes in stain removal by the various denture cleaners used in the study.