Best clinical practice guidance for treating deep carious lesions in primary teeth: an EAPD policy document

Purpose

The European Academy of Paediatric Dentistry (EAPD) has developed this best clinical practice guidance to help clinicians manage deep carious lesions in primary teeth.

Methods

Three expert groups conducted systematic reviews of the relevant literature. The topics were: (1) conventional techniques (2) Minimal Intervention Dentistry (MID) and (3) materials. Workshops were held during the corresponding EAPD interim seminar in Oslo in April 2021. Several clinical based recommendations and statements were agreed upon, and gaps in our knowledge were identified.

Results

There is strong evidence that indirect pulp capping and pulpotomy techniques, and 38% Silver Diamine Fluoride are shown to be effective for the management of caries in the primary dentition. Due to the strict criteria, it is not possible to give clear recommendations on which materials are most appropriate for restoring primary teeth with deep carious lesions. Atraumatic Restorative Technique (ART) is not suitable for multi-surface caries, and Pre-formed Metal Crowns (PMCs) using the Hall technique reduce patient discomfort. GIC and RMGIC seem to be more favourable given the lower annual failure rate compared to HVGIC and MRGIC. Glass carbomer cannot be recommended due to inferior marginal adaptation and fractures. Compomers, hybrid composite resins and bulk-fill composite resins demonstrated similar values for annual failure rates.

Conclusion

The management of deep carious lesions in primary teeth can be challenging and must consider the patient’s compliance, operator skills, materials and costs. There is a clear need to increase the use of MID techniques in managing carious primary teeth as a mainstream rather than a compromise option.

What the future holds for regenerative endodontics: novel antimicrobials and regenerative strategies

Regenerative/revitalisation endodontic techniques are increasingly used as a treatment approach for the management of immature permanent teeth with necrotic pulps. Different chemical irrigants and medicaments are routinely used clinically for intra-canal disinfection. However, despite remarkable progress in this field, coronal discolouration, cell cytotoxicity, difficulty of removal of organic biofilm from the root canal, development of sensitisation and antimicrobial resistance are still challenges to this line of treatment. This review critically discusses and challenges the current status quo of antimicrobials used in regenerative endodontics and sheds the light on future alternative antimicrobial materials with regenerative potential.

Investigating the vascularization capacity of a decellularized dental pulp matrix seeded with human dental pulp stem cells: in vitro and preliminary in vivo evaluations

AIM

To investigate the vascularization capacity of a decellularized dental pulp matrix (DDP) of bovine origin seeded with human dental pulp stem cells (hDPSCs) in vitro and to present preliminary in vivo findings.

METHODOLOGY

Bovine dental pulps were decellularized and then analysed using histological staining and DNA quantification. The resultant DDPs were characterized using immunohistochemical staining for the retention of vascular endothelial growth factor A (VEGF-A) and fibroblast growth factor 2 (FGF-2). Furthermore, DDPs were recellularized with hDPSCs and analysed histologically. The expression of markers involved in angiogenesis by hDPSCs colonizing the DDPs was assessed in vitro. A preliminary in vivo study was then conducted in which hDPSCs-seeded and unseeded DDPs were inserted in debrided human premolars root slices and implanted subcutaneously in immunodeficient mice. Samples were retrieved after 30 days and analysed using histological and immunohistochemical staining. The independent samples t-test, analysis of variance and a Kruskal-Wallis test were used to analyse the quantitative data statistically depending on the group numbers and normality of data distribution. The difference between the groups was considered significant when the P-value was less than 0.05.

RESULTS

Acellular dental pulp matrices were generated following bovine dental pulp decellularization. Evaluation of the developed DDPs revealed a significant DNA reduction (P < 0.0001) with preservation of the native histoarchitecture and vasculature and retention of VEGF-A and FGF-2. Upon recellularization of the DDPs with hDPSCs, the in vitro analyses revealed cell engraftment with progressive repopulation of DDPs' matrices and vasculature and with enhanced expression of markers involved in angiogenesis. In vivo implantation of root slices with hDPSCs-seeded DDPs revealed apparent vascularization enhancement as compared to the unseeded DDP group (P < 0.0001).

CONCLUSIONS

The developed decellularized dental pulp matrix had pro-angiogenic properties characterized by the retention of native vasculature and angiogenic growth factors. Seeding of hDPSCs into the DDP led to progressive repopulation of the vasculature, enhanced expression of markers involved in angiogenesis in hDPSCs and improved in vivo vascularization capacity. The se suggest that a combination of DDP and hDPSCs have the potential to provide a promising vascularization promoting strategy for dental pulp regeneration.

RV Pacing Percentage

Introduction

Chronic right ventricular pacing (RVP) has been associated with dyssynchrony, leading to increased mortality. However, there have been discrepancies in previous reports in the effect of RVP levels.

Objective

To sub-stratify mortality risk by age for different RVP level groups within a large real-world ICD cohort.

Methods

Optum® de-identified electronic health records were linked to the Medtronic Carelink data to identify dual chamber ICD recipients (2007–2017). RVP level was based on median daily pacing during the first 90 days post-implant and categorized either into groups with a cutoff of 40%, or with groups of 0–9%, 10–19%, 20–29%, 30–39%, 40–49%, and 50–100%. The endpoint was death more than 90 days post-implant. Kaplan-Meier survival curves, log-rank tests, and Cox regression were used to analyze the relationship between RVP and risk of death.

Results

Among 14,832 ICD patients (median age 67; 74.0% male), there were 2,602 deaths within 10 years after implant. In unadjusted comparisons, high RVP (&gt;40%) increased the risk of death relative to low RVP (≤40%) (p&lt;0.001). This effect remained significant in older cohort (≥67 years old at implant) (p&lt;0.001), but not in younger cohort (&lt;67 years old) (p=0.955) (Figure). After controlling for age, gender, pacing mode, MI, SCA, HF hospitalization, diabetes, and renal dysfunction, similar or increased risk was associated with higher pacing groups relative to the 0–9% pacing group in the older cohort, but not in the younger cohort.

Conclusions

Our data from a large contemporaneous real-world source suggests that older age or characteristics associated with age make patients more sensitive to chronic RVP effects. These results help reconcile differences observed in prior studies.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic, Inc.

Best clinical practice guidance for local analgesia in paediatric dentistry: an EAPD policy document

BACKGROUND

The European Academy of Paediatric Dentistry (EAPD) proposes this best-practice guidance to help practitioners to decide when and how to use local analgesia to control pain in children, adolescents, and medically compromised individuals during the delivery of oral health care.

METHODS

A search of different databases was conducted using all terms relevant to the subject. Relevant papers were identified after a review of their titles, abstracts or full papers. Three workshops were held during the corresponding EAPD interim seminar in Torino (Italy) in 2017. Several statements were agreed upon and, furthermore, knowledge gaps were identified.

RESULTS

An important outcome was that when local analgesia administered appropriately-correct choice of agent(s) and dosage, proper route of administration-it is, firstly, clinically effective for pain-control in treating children and, secondly, it carries a very low risk of morbidity including adverse or side-effects. Furthermore, several gaps in knowledge were identified during the workshop which indicates future research needs. Most importantly it remains unsatisfactory that in several European countries the most frequently used injectable local analgesic agent, articaine, is not approved for usage in children below the age of 4 years.

CONCLUSION

When considering the dental demand to treat vulnerable (medically compromised) children and adolescents in a safe, painless, less-invasive and effective way, there seems to be an urgent need to close these gaps in knowledge.

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

Aim

This 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.

Results

Variable 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.

Conclusions

Based 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.

Comparing clinical outcomes in HIV-infected and uninfected older men hospitalized with community-acquired pneumonia

OBJECTIVES

Outcomes of community-acquired pneumonia (CAP) among HIV-infected older adults are unclear.

METHODS

Associations between HIV infection and three CAP outcomes (30-day mortality, readmission within 30 days post-discharge, and hospital length of stay [LOS]) were examined in the Veterans Aging Cohort Study (VACS) of male Veterans, age ≥ 50 years, hospitalized for CAP from 10/1/2002 through 08/31/2010. Associations between the VACS Index and CAP outcomes were assessed in multivariable models.

RESULTS

Among 117 557 Veterans (36 922 HIV-infected and 80 635 uninfected), 1203 met our eligibility criteria. The 30-day mortality rate was 5.3%, the mean LOS was 7.3 days, and 13.2% were readmitted within 30 days of discharge. In unadjusted analyses, there were no significant differences between HIV-infected and uninfected participants regarding the three CAP outcomes (P > 0.2). A higher VACS Index was associated with increased 30-day mortality, readmission, and LOS in both HIV-infected and uninfected groups. Generic organ system components of the VACS Index were associated with adverse CAP outcomes; HIV-specific components were not. Among HIV-infected participants, those not on antiretroviral therapy (ART) had a higher 30-day mortality (HR 2.94 [95% CI 1.51, 5.72]; P = 0.002) and a longer LOS (slope 2.69 days [95% CI 0.65, 4.73]; P = 0.008), after accounting for VACS Index. Readmission was not associated with ART use (OR 1.12 [95% CI 0.62, 2.00] P = 0.714).

CONCLUSION

Among HIV-infected and uninfected older adults hospitalized for CAP, organ system components of the VACS Index were associated with adverse CAP outcomes. Among HIV-infected individuals, ART was associated with decreased 30-day mortality and LOS.

The effect of premature extraction of primary teeth on the subsequent need for orthodontic treatment

AIM

To investigate if premature extraction of primary teeth was associated with orthodontic need in the permanent dentition.

STUDY DESIGN

This was a case-control study based on retrospective dental records.

METHODS

As part of NHS (UK) Dental Epidemiology Programme a sample of 366, 12-year-old children from Bradford and Airedale were examined. The survey collected data on patient demographics, dental health status including orthodontic need. Data linkage was undertaken for those children participating in the NHS Dental Epidemiology Programme who had previously accessed the local Salaried Dental Service (SDS). For these children, retrospective dental information was collected about premature extraction of primary teeth.

RESULTS

From the 366 children who were surveyed, 116 children had received treatment at the local SDS in the past. Significantly more children from ethnic minorities, low socioeconomic backgrounds and high caries rate (p < 0.001) were seen in the SDS. For the 107 children who attended SDS, an increased total number of primary teeth extractions was positively associated with orthodontic need (odds ratio:1.18, CI -1.01 to 1.37).

STATISTICS

Multilevel modelling was undertaken to identify variables associated with orthodontic need.

CONCLUSIONS

In the study group, orthodontic need was significantly associated with the number of primary teeth extracted.

Equivalency study of histological responses to complete or partial pulpotomies in inflamed baboon immature first permanent molars

Partial pulpotomy is an accepted treatment for traumatised incisor teeth with exposed pulps. Clinical studies in humans suggest that this may also be an acceptable technique for carious exposed pulps in molar teeth, but objective histological evidence to support this perception is lacking.

OBJECTIVE

To compare histological responses to complete or partial pulpotomies of inflamed pulps in immature baboon first permanent molar teeth.

METHODS

An experimental study in the baboon (Papio ursinus). Pulpitis was induced with fresh Streptococcus mutans placed into occlusal cavities with a small pulpal exposure in 34 first permanent molars of 9 juvenile baboons. After 14 days a pulpotomy, either complete or partial, was performed on the same molars in contra-lateral quadrants using calcium hydroxide covered with IRM and amalgam. After 90 days specimens were harvested and examined under the light microscope with the examiner blind to the treatment.

RESULTS

Reaction frequencies in the complete and partial pulpotomy teeth were: dentine bridges 9/16 and 10/16, viable pulp in root canals 10/16 and 13/18, peri-apical abscesses 3/13 and 4/13. Fisher's exact probability test showed no statistically significant rates between the groups.

CONCLUSIONS

Complete or partial pulpotomy of inflamed pulps in immature baboon first permanent molars produced comparable reactions.

Zinc oxide-eugenol and calcium hydroxide pulpectomies in baboon primary molars: histological responses

AIM

To compare histological responses to zinc oxide-eugenol (ZOE) and calcium hydroxide (CH) pulpectomies in primary molar teeth with inflamed pulps.

STUDY DESIGN

This was an experimental study in 17 juvenile baboons (Papio ursinus).

METHODS

Pulpitis was induced with fresh human carious dentine or Streptococcus mutans placed into occlusal cavities in 78 primary molars; after 14 days a pulpectomy was performed on the same primary molars with the two root fillings randomly allocated. The root canal openings were then covered with IRM and the cavity filled with amalgam. After 90 days specimens were harvested and examined under the light microscope with the examiner blind to the treatment.

RESULTS

Reaction frequencies in the ZOE-treated versus CH-treated teeth were: no recognisable pulp 89% and 82%, internal root resorption 0% and 1%, external root resorption 11% and 24%, presence of bacteria 5% and 18%, periapical abscesses 24% and 52%.

STATISTICS

Fisher's exact probability test showed a statistically significant higher prevalence of periapical abscesses in the CH-treated group (P=0.03, relative risk 2.2).

CONCLUSIONS

ZOE pulpectomy is preferred to CH for the treatment of infected pulps in primary molars.

Pulpitis induction in baboon primary teeth using carious dentine or Streptococcus mutans

The objective of this equivalency study was to see if a colony of Streptococcus mutans placed into cavities in primary molar teeth produced pulpitis similar to an established pulpitis induction method using carious dentine. In two juvenile baboons (Papio ursinus), occlusal cavities were cut in all 16 primary molar teeth, followed by making a small pulpal exposure after which the cavity was swabbed with 37 per cent phosphoric acid. In one half of the teeth, fresh soft human carious dentine was placed over the pulpal exposure; in the remaining teeth the exposure was covered with a colony of Streptococcus mutans in agar. All the cavities were restored with unlined light-cured composite resin. After 14 days specimens were harvested and examined under the light microscope with the examiner blind to the induction method. In both groups of teeth there was recognisable pulp, hyperaemia, micro-abscesses in the pulp and peri-apical abscesses. Reactions to soft caries were more severe than to Streptococcus mutans. The results show that Streptococcus mutans placed in a cavity with an exposure produces comparable pulpitis to fresh soft human carious dentine in the same type of cavity and that both methods produce pulpitis suitable for testing pulpotomy or pulpectomy treatments.

Judgement criteria for molar incisor hypomineralisation (MIH) in epidemiologic studies: a summary of the European meeting on MIH held in Athens, 2003

AIM

This paper reviews the proceedings and conclusions of a meeting of experts concerned with the problem of hypomineralised incisors and molars (MIH). The aims of this meeting were to establish criteria for the judgement of MIH, to select representative cases and to discuss how the name of the condition was best described as hypomineralised, or hypomaturated, first permanent molars.

CONCLUSION

There was not complete agreement as to the correct diagnosis and aetiology of the condition. A suggested list of definitions of the judgement criteria to be used in diagnosing Molar Incisor Hypomineralisation (MIH) for prevalence studies was agreed upon.

Ferric sulphate and formocresol pulpotomies in baboon primary molars: histological responses

AIM

To compare pulpal reactions to ferric sulphate and formocresol pulpotomies in primary molar teeth with inflamed pulps.

STUDY DESIGN

An experimental study in 15 juvenile baboons (Papio ursinus).

MATERIALS AND METHODS

Pulpitis was induced with fresh human carious dentine or Streptococcus mutans placed into occlusal cavities in 57 primary molars; after 14 days a pulpotomy was performed on the same primary molars with the two pulp medicaments randomly allocated; the pulp was covered with IRM and the cavity filled with amalgam. After 90 days specimens were harvested and examined under the light microscope with the examiner blind to the treatment.

RESULTS

Reaction frequencies in the ferric sulphate-treated and formocresol-treated teeth were: recognisable pulp 52% and 50%, dentine bridges 16% and 12%, internal root resorption 12% and 4%, external resorption 28% and 31%, bacteria 12% and 23%, peri-apical abscesses 32% and 38%.

STATISTICS

Fisher's exact probability test showed no statistically significant differences between reaction frequencies in the two treatment groups.

CONCLUSION

A pulpotomy in a primary tooth may be clinically successful in the presence of adverse histological reactions.

Animal bite management practices: a survey of health care providers in a community development block of Haryana

It is seen that outcome of animal bites is influenced by various factors including the treatment procedures practiced by health care providers (HCPs). A cross sectional study of health care providers was conducted during May 2000 in PHC Kurali and Naraingarh town of community development block Naraingarh in district Ambala, Haryana. A total of forty-four HCPs were interviewed at their health facility. They were asked about the qualification and number of years in practice. Health care providers were assessed for their knowledge regarding history taking, immediate management of animal bite, post bite anti-rabies treatment, follow up advice and availability of vaccines. Pre-exposure prophylaxis was known to 18.8% of HCPs. Fifty-nine per cent of HCPs were confident in managing dog bites and 93.1% knew about tissue culture vaccine. Vaccine cost was the commonest barrier (38.8%) in the management of animal bites. This study shows a gross difference between awareness and actual practice of management of animal bites.

Oral management of patients following oncology treatment: literature review

Many tumours of the head and neck are treated by clinical oncologists using radiotherapy. This treatment modality is particularly effective in destroying rapidly dividing cells, hence its value in cancer treatment. The tissues of the oral mucosa, the salivary glands and blood vessels can be damaged as the result of radiotherapy treatment. As a result, patients experience unwanted oral effects that have both short and long-term implications. The outlook following treatment for head and neck cancer continues to improve and, as people keep their teeth into later life, dentists will increasingly be expected to address the oral problems that patients experience after radiotherapy. The aim of this article is to review the current literature concerning the implications and management of these oral implications of cancer treatment.