Dentists' knowledge of dental trauma based on the International Association of Dental Traumatology guidelines: An Australian survey

Background/Aim

Traumatic dental injuries are the result of impact injuries to the teeth and/or soft and hard tissues within and around the vicinity of the oral cavity and pose a very serious public health dilemma. The aim of this study was to appraise the level of knowledge of dentists in Australia regarding the management of traumatic dental injuries based on the International Association of Dental Traumatology (IADT) guidelines.

Methodology

A link to an electronic questionnaire investigating personal and professional information and twelve questions about dental trauma was distributed by email using the Qualtrics Survey Software to ensure anonymity of the respondents, to members of the Australian Dental Association. The respondents were grouped according to demographic characteristics and practice profiles. Data were evaluated by the Student’s T test or one‐way ANOVA with post hoc testing using Fisher's least significant difference, with the α level set at 5%.

Results

A total of 180 complete responses were obtained. The overall mean number of correct answers was 7.55 ± 1.91 from a maximum possible score of twelve. Gender, year of primary dental qualification, dentist identity (general dentist or specialist), area of main practice or region worked by the practitioner did not significantly affect the mean scores. However, increased knowledge of the IADT guidelines was significantly associated with the number of trauma cases treated and the dentists' self‐reported knowledge.

Conclusions

The overall knowledge of Australian dentists regarding the management of traumatic dental injuries based on the IADT guidelines was generally good but it was also deficient in some areas.

Tooth Resorption - Part 1: The evolvement, rationales and controversies of tooth resorption

In 1966, Andreasen and Hjørting‐Hansen were the first to describe a relationship between tooth resorption and dental trauma. However, Andreasen's original classification did not include other resorptive processes which have since been identified. Numerous articles have been published suggesting new terminology and definitions for tooth resorption. A uniform language with universally accepted terminology is crucial to eliminate the multiplicity of terms and definitions which only cause confusion within the profession. An electronic literature search was carried out in the PubMed database using the following keywords for articles published in English: “root resorption,” “inflammatory root resorption,” “replacement resorption,” “cervical resorption,” “trauma,” “ankylosis,” “surface resorption,” and “internal resorption.” The search also included textbooks and glossaries that may not have surfaced in the online search. This was done to identify articles related to tooth resorption and its etiology in dentistry. The aim of this review was to present the history that has led to the variety of terms and definitions for resorption. This review emphasizes the need for a clearer, simpler, and more comprehensive nomenclature for the various types of tooth resorption which are presented in Part 2 of this series.

A critical analysis of research methods and experimental models to study tooth discolouration from endodontic materials

As a range of materials used in endodontics may cause tooth discolouration, exploration of factors responsible for the darkening of the tooth crown or root is warranted. This narrative review paper discusses the range of technical factors that apply in laboratory studies that assess endodontic discolouration. As an example of how these factors operate, particular examples relating to discolouration caused by endodontic medicaments containing tetracycline antibiotics are used. Following the PRILE 2021 guidelines approach, a summary of key variables to be addressed in the methodology for laboratory studies is presented, to inform future work.

Methodological quality assessment criteria for the evaluation of laboratory-based studies included in systematic reviews within the specialty of Endodontology: a development protocol

High quality systematic reviews in the field of Dentistry provide the most definitive overarching evidence for clinicians, guideline developers and healthcare policy makers to judge the foreseeable risks, anticipated benefits, and potential harms of dental treatment. In the process of carrying out a systematic review, it is essential that authors appraise the methodological quality of the primary studies they include, because studies which follow poor methodology will have a potentially serious negative impact on the overall strength of the evidence and the recommendations that can be drawn. In Endodontology, systematic reviews of laboratory studies have used quality assessment criteria developed subjectively by the individual authors as there are no comprehensive, well-structured, and universally accepted criteria that can be used objectively and universally to individual studies included in reviews. Unfortunately, these subjective criteria are likely to be inaccurately-defined, unreliably-applied, inadequately-analysed, unreasonably-biased, defective, and non-repeatable. The aim of the present paper is to outline the process to be followed in the development of comprehensive methodological quality assessment criteria to be used when evaluating laboratory studies that should be included in systematic reviews within Endodontology. The development of new methodological quality assessment criteria for appraising the laboratory-based studies included in systematic reviews within Endodontology will follow a three-stage process. First, a steering committee will be formed by the project leaders to develop a preliminary list of assessment criteria by modifying and adapting those already available, but with the addition of several new items relevant for Endodontology. The initial draft assessment criteria will be reviewed and refined by a Delphi Group (n=40) for their relevance and inclusion using a nine-point Likert scale. Second, the agreed items will then be discussed in an online or face-to-face meeting by a group of experts (n=10) to further refine the assessment criteria. Third, based on the feedback received from the online/face-to-face meeting, the steering committee will revise the quality assessment criteria and subsequently a group of authors will be selected to pilot the new system. Based on the feedback collected, the criteria may be revised further before being approved by the steering committee. The assessment criteria will be published in relevant journals, presented at national and international congresses/meetings, and will be freely available on a dedicated website. The steering committee will update the assessment criteria periodically based on feedback received from end-users.

Present status and future directions - managing endodontic emergencies

Endodontic emergencies are common in both general dental practices and specialist Endodontic practices. The aim of this review is to provide an overview of endodontic emergencies. Endodontic emergencies can be a result of many different conditions of the pulp, root canal and periradicular tissues. They may occur before endodontic treatment has been started, between appointments when treatment is being performed over multiple visits, or after endodontic treatment has been completed. In the latter situation, the emergency may be very soon after the treatment or it may occur many years later, in which case it is usually a new disease process as a result of the root canal system becoming infected. An emergency can be a stressful situation for both the patient and the dentist (or endodontist) as it is usually an unexpected event. It is incumbent on dental professionals to provide timely assistance to patients who have an emergency, and it is also important to allow sufficient time to manage the situation comprehensively. Management of endodontic emergencies should follow the principles of the 3D's - Diagnosis, Definitive dental treatment and Drugs - and in that sequence. An accurate diagnosis, the first "D", is essential so the appropriate treatment can be provided. Diagnosis requires a thorough understanding of the various conditions that can cause the emergency and this can be helped by having a comprehensive classification of the various conditions. The diagnosis should also direct the clinician to the appropriate definitive dental treatment, the second "D". Root canal treatment will not always be required as some cases can be managed conservatively. Other cases may require root canal re-treatment. The specific details of how the treatment is done can also vary, according to the diagnosis. The final "D" is Drugs - the use of drugs should also be dependent on the diagnosis and the dental treatment. Drugs should only be an adjunct following the treatment. The clinician must also differentiate between inflammation and infection in order to provide the appropriate treatment and to prescribe the appropriate medication for effective pain relief and resolution of other symptoms or signs such as swelling.

Effect of different concentrations of sodium hypochlorite on the compressive strength of endodontically-treated roots

INTRODUCTION

The aim was to compare the compressive strength of dentin after irrigation with different concentrations of sodium hypochlorite (NaOCl).

METHODS

Two hundred and fifty-nine extracted human tooth roots with no root caries or previous endodontic treatment were collected. They were sorted by size and length, and assigned to 7 groups (n=37): negative control (no instrumentation, no irrigant), positive control (saline irrigant), 1%, 2.5%, 4%, 5.25%, and 10% NaOCl. A total of 13 mL NaOCl or saline (in 1mL increments) was used per canal while being instrumented to #35 files (approximately 13 min). EDTAC (15%) was then used to remove smear layer (2 min), followed by NaOCl as a final rinse. The roots were sectioned into 2mm thick discs and subjected to compression testing.

RESULTS

There was a significant difference between the negative control group and all instrumented groups (P < .05). The positive control group was significantly different to the 5.25% group (P < .05) and had a low P-value when compared to the 2.5% group and the other higher concentrations (P ≅ .1). When the NaOCl groups were compared to each other, there was a significant difference between 1% NaOCl and all higher concentrations (P < .05), but no significant difference when 2.5% NaOCl was compared to higher concentrations.

CONCLUSION

A concentration of 1% NaOCl had the least effect on the compressive strength of dentin and this was significantly different to all higher concentrations tested. Therefore, the use of concentrations of NaOCl above 1% should be reconsidered.

An evaluation of the repeatability of electric pulp sensibility tests

The accuracy, reliability and reproducibility of electric pulp tests (EPT) have been investigated but there is conflicting information about their repeatability. The aim of this study was to investigate whether EPT are repeatable over time. EPT results from 180 healthy teeth in 39 patients with 2-10 readings per tooth (total 692 readings) were analysed. Single measures intraclass correlation coefficients (ICC) ranged from 0.776 to 0.845 in teeth with 2-7 repeated measures (P < 0.001), indicating good repeatability. With eight or more measures per tooth, the ICC was low, indicating poor repeatability over longer follow-up times, but only seven teeth in two subjects were included in this analysis. The Pearson correlation showed no statistically significant correlation for 2-7 readings but when all readings were included, there was a statistically significant negative correlation. Hence, EPT has good repeatability.

Revised guidelines for the endodontic education of dentistry students in Australia and New Zealand (FEBRUARY 2021)

These revised guidelines for contemporary endodontic education in Australia and New Zealand (version 2021) propose the minimum criteria for the training of dentistry students. The document contains a definition of endodontics and a description of the scope of endodontics. It proposes a general outline for education programmes in endodontics as part of general dental practice.

Impact of root canal treatment on high-sensitivity C-reactive protein levels in systemically healthy adults with apical periodontitis - a preliminary prospective, longitudinal interventional study

AIM

To assess the influence of root canal treatment on serum high-sensitivity C-reactive protein (hsCRP) levels in systemically healthy human adults.

METHODOLOGY

Fifteen individuals aged 20-40 years diagnosed with apical periodontitis [Periapical Index (PAI) score ≥3] who were otherwise healthy took part in this prospective interventional study. Patients with moderate to severe periodontitis, systemic diseases and traditional cardiac risk factors (hypertension, diabetes, dyslipidemia and smoking) were excluded. Root canal treatment was completed in two visits with an inter-appointment calcium hydroxide intracanal medicament. After 6 months, healing of apical periodontitis was evaluated clinically and radiographically, and serum hsCRP levels were recorded. A paired sample T-test was used to compare the mean hsCRP values between the pre- and post-treatment groups. The Mann-Whitney U test was used to compare hsCRP values between patients with PAI scores of 3 and 4, and the Wilcoxon signed-rank test was used to compare pre- and postoperative PAI scores.

RESULTS

The mean preoperative baseline serum hsCRP level was 2.88 ± 1.06 mg L^-1 which can be associated with a moderate risk for cardiovascular disease (CVD). Based on the preoperative hsCRP levels, eight of the 15 patients were categorized as high risk (hsCRP > 3 mg L^-1 ) and the other seven as medium risk (hsCRP 1-3 mg L^-1 ) for CVD. The mean preoperative hsCRP value of patients with a PAI score of 3 was 2.88 ± 1.19 mg L^-1 , and the mean preoperative hsCRP of patients with a PAI score of 4 was 2.87 ± 0.15 mg L^-1 , which was not significantly different (P = 0.942). Six months after root canal treatment, the mean PAI score had significantly reduced from 3.2 ± 0.42 to 1.4 ± 0.69 (P = 0.003). The PAI score had reduced to ≤2 in 87% of the patients, and the mean serum hsCRP levels had significantly reduced to 1.34 ± 0.52 mg L^-1 (P < 0.001). Ten of the 15 patients had a reduction in their CVD risk status.

CONCLUSIONS

This study suggests that root canal treatment can reduce serum hsCRP levels in systemically healthy individuals with apical periodontitis.

Comparing the anaesthetic efficacy of 1.8 mL and 3.6 mL of anaesthetic solution for inferior alveolar nerve blocks for teeth with irreversible pulpitis: a systematic review and meta-analysis with trial sequential analysis

BACKGROUND

The scientific literature is contradictory in relation to selecting the appropriate volume of local anaesthetic solution for inferior alveolar nerve blocks (IANB) when attempting to anaesthetize mandibular teeth with irreversible pulpitis.

OBJECTIVES

To compare the efficacy of 1.8 and 3.6 mL of the same anaesthetic solution for IANBs when treating mandibular teeth with irreversible pulpitis.

METHODS

A literature search was performed in PubMed, Scopus and EBSCOhost databases until May 2020. Randomized clinical trials published in English, comparing 1.8 with 3.6 mL of the same anaesthetic solution for IANBs in permanent mandibular teeth with irreversible pulpitis, were included. The risk of bias of the included trials was appraised using the revised Cochrane risk of bias tool. A meta-analysis was performed using the random-effects model. The effect of random errors on the results of the meta-analysis was evaluated by trial sequential analysis and the quality of evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Four clinical trials involving 280 teeth from patients with ages ranging from 18 to 65 years were included. Among the four trials, three were categorized as having a 'low' risk of bias and one was categorized as having 'some concerns'. The primary meta-analysis revealed that 3.6 mL of anaesthetic solution when administered for IANBs was associated with significantly greater success rates compared with 1.8 mL (RR = 1.94; 95% CI, 1.07, 3.52; I²  = 77%). Similarly, the results of the sensitivity analysis (restricting trials only to those that used the Heft-Parker visual analogue pain scale) revealed that the use of 3.6 mL significantly increased the success of IANBs compared with 1.8 mL. The trial sequential analysis confirmed the evidence for the beneficial effect of 3.6 mL to achieve success for IANBs was 'conclusive'. The quality of evidence was graded as 'high'.

CONCLUSION

Increasing the volume of anaesthetic solution from 1.8 to 3.6 mL improved the success rate for IANBs in mandibular molars with irreversible pulpitis. The quality of the evidence was 'high'. Future high-quality clinical trials are required with different types of anaesthetic solutions and other types of teeth.

The scope of practice of the modern Endodontist in Western Australia

There are limited data regarding the scope of practice of Endodontists in Australia. The aim of this study was to investigate the scope of practice of Endodontists and Endodontic Registrars in Western Australia. The study comprised a three-part survey relating to demographics, clinical factors and materials and equipment. The response rate was 70.6%. Compared to the public sector, clinicians in the private sector treated on average twice as many patients per day, twice as many trauma cases per year and, as a proportion of all cases, four and a half times as many apical surgical procedures. These aspects were all statistically significantly different. Other aspects were similar to previous studies within Australia and from other countries.

Revised guidelines for educational requirements for specialisation in endodontics in Australia and New Zealand (July 2020)

These revised guidelines developed by the Australian Society of Endodontology Inc. and the Australian and New Zealand Academy of Endodontists for educational requirements for specialisation in endodontics in Australia and New Zealand (version 2020) propose minimum criteria for training specialists in our field. The document contains a definition of endodontics and a description of the scope of endodontics. It proposes criteria for selection of the students and describes the proposed main features and a general outline of the education programme.

Pre-operative ketorolac efficacy with different anesthetics, irrigants during single visit root canal treatment of mandibular molars with acute irreversible pulpitis

Mandibular molar teeth with acute irreversible pulpitis pose challenges in single visit root canal treatment - (i) success of local anaesthesia and (ii) post-operative pain. One hundred and twenty-six patients with pain associated with carious mandibular molar teeth were enrolled. All patients were administered 10 mg of ketorolac tromethamine prior to local anaesthesia. Local anesthetics used were 2% lignocaine with 1:80 000 adrenaline and 4% articaine with 1:100 000 adrenaline. Three irrigation solutions were used - saline, 3% sodium hypochlorite and dexamethasone. Mean intra-operative pain scores for the lignocaine and articaine groups were 4.33 (±2.58) and 4.22 (±2.88), respectively. There was a statistically significant difference (P = 0.000) in post-operative pain incidence between the lignocaine and articaine groups with 16.7% (10 patients) and 49.2% (29 patients), respectively. Pre-operative ketorolac tromethamine was not effective in reducing the intra-operative pain incidence. However, it was effective in controlling post-operative pain with lignocaine anesthetic group.