Trauma in Permanent Teeth: Factors Associated with Adverse Outcomes in a University Pediatric Dental Clinic

PURPOSE

The purpose of this study was to determine variables associated with adverse outcomes among traumatized permanent teeth in a university pediatric dental clinic.

METHODS

Electronic charts of children treated at a university-based dental clinic for trauma in permanent teeth were analyzed. Variables evaluated included demographics (age, sex, American Society of Anesthesiologists classification, and insurance type), affected tooth location, trauma characteristics, type of dental trauma, elapsed time between trauma and initial treatment, elapsed time between the initial and final treatment, initial treatment type, and initial and final restoration type. Adverse outcomes were defined as root canal treatment, decoronation, and extraction. Associations between adverse outcomes and each variable of interest were calculated using chi-square and Fisher's exact test and logistic regression. The significance level was set at five percent.

RESULTS

Adverse outcomes were significantly associated with the type of dental trauma (P=0.001), presence of luxation injury (P=0.048), initial dental treatment (P<0.001), and initial dental restoration type (P=0.019).

CONCLUSIONS

Treating dental trauma in permanent teeth in a timely manner can strongly impact their prognosis.

Retrospective Study of the Survival Rates of Indirect Pulp Therapy Versus Different Pulpotomy Medicaments

PURPOSE

The purposes of this retrospective chart review were to determine: (1) how primary molars in need of vital pulp therapy (VPT) have been treated over a period of four years at a university-based pediatric dental practice (UBP); and which treatments-indirect pulp therapy (IPT), formocresol pulpotomy (FCP), and ferric sulfate pulpotomy (FSP)-have been successful.

METHODS

Electronic patient records (axiUm) that contained the procedure codes D3120 (pulp cap-indirect) or D3220 (therapeutic pulpotomy) were totaled by year. Visit records were queried again to identify treatment failures (i.e., extractions [D7140] or pulpectomy [D3221/D3240]). A total of 2,001 primary molar teeth were included in the study. Success was compared using a Kaplan-Meier analysis.

RESULTS

At the three-year follow-up, IPT had a 96.2 percent survival rate, FCP had a 65.8 percent survival rate, and FSP had a 62.9 percent survival rate (P<.0001).

CONCLUSIONS

Over a four-year period of time, IPT became the more commonly used vital pulp therapy treatment at a university-based pediatric dental practice and had a significantly better survival rate than FCP or FSP.

Pulp exposures in adults--choice of treatment among Swedish dentists

This study comprises a survey of Swedish dentists'treatment preferences in cases of carious exposure of the dental pulp in adults.The survey was conducted as part of a comprehensive report on methods of diagnosis and treatment in endodontics, published in 2010 by the Swedish Council on Health Technology Assessment. A questionnaire was mailed to a random subsample of 2012 dental offices where one dentist at each office was requested to answer all questions. Each questionnaire contained one of three sets of questions about endodontic practice routines.Thus around one-third of the subsample received case-specific questions about treating carious exposure. Only general practitioners aged below 70 years were included.The final study sample comprised 412 participants.The dentists were presented with two case scenarios. In Case 1 a 22-year old patient had a deep carious lesion in tooth 36 and in Case 2 a 50-year old patient had a deep carious lesion in tooth 14.The participants were asked to nominate their treatment of choice: pulp capping, partial pulpotomy or pulpectomy. For Case 1, 17 per cent of the respondents selected pulpectomy; the corresponding rate for Case 2 was 47 per cent. Female gender and age group 25-49 years were predictive of selection of less invasive treatment options. However, according to recent guidelines (2011) from the National Board of Health and Wellfare, Swedish dentists are recommended to elect pulpectomy prior to pulp capping/partial pulpotomy when confronted with a tooth having a cariously exposed pulp in adults.

Restorative Treatment Decisions for Deep Proximal Carious Lesions in Primary Molars

AIM

To assess clinicians' individual variables that might influence decision-making for the restoration of deep proximal carious lesions in primary molars.

METHODS

A pre-coded questionnaire that sought participants' treatment choices for a deeply carious second mandibular primary molar, as depicted in a simulated periapical radiograph, along with a specific clinical scenario, was distributed among a random sample of 157 dentists and 15 paediatric dentists. Participants were asked to answer questions. After combining the pulpotomy and pulpectomy treatment choices under a 'pulp therapy' category, a binary dependent variable was constructed. Logistic regression of the ratio of the participants who would restore the questioned tooth by a method in question, was run.

RESULTS

A total of 155 dentists (116 males and 39 females) completed the survey, giving a response rate of 90%. Of these 53% of dentists recommended pulpotomy followed by definitive restoration and 39% recommended removal of caries and restoration without pulp therapy. In the logistic regression model, males and graduates of English language undergraduate dental programs had higher probabilities of restoring without prior pulp therapy (p<0.03 and p<0.02, respectively). Compared with graduates of Asian programs, dentists who graduated from Eastern Europe and the Middle East, showed lower likelihoods of restoring the tooth without prior pulp therapy (p<0.01 and p<0.004, respectively). Dentists who treated an average of 6-16 child patients during a week had a lower probability of restoring the tooth without prior pulp therapy than those who were not currently involved in treating children (p<0.01). No other measured variables were associated with participant's treatment choices.

CONCLUSIONS

The lack of agreement among dentists regarding their optimal treatment recommendations for deep proximal carious lesions appears to be due mainly to inter-individual, educational, training and practice characteristic factors.

Differences in pediatric dental services under general anesthesia for Medicaid and military dependent children

PURPOSE

This study's purpose was to compare pediatric dental services provided for Medicaid and military dependent children to determine if differences in dental treatment choices exist based on site and payment method.

METHODS

Subjects included 120 Medicaid patients at the University of Texas Health Science Center at San Antonio and 120 military dependents at Lackland Air Force Base, Texas. Demographic data and treatment information were abstracted for children younger than 6 years old receiving dental treatment under general anesthesia between 2002 and 2006. Data was analyzed using Wilcoxon rank sum, Kruskal-Wallis, and Fisher's exact tests.

RESULTS

The Medicaid recipients were younger (40.2 vs 49.8 months, P<.001) and more likely to be Hispanic (78% vs 30%, P<.001). The means of decayed teeth, fillings, and stainless steel crowns did not differ between sites. Medicaid children received more composite fillings (P<.001), fewer amalgam fillings (P<.001), fewer pulp therapies (P<.001), more extractions (P=.01), and fewer sealants (P<.001). Age and gender did not affect decay rates, but those of Hispanic ethnicity did experience more decay than non-Hispanics (9.5 vs 8.6, P=.02).

CONCLUSION

This study found no difference in the number of less conservative, albeit more costly, procedures performed with Medicaid children at a university compared to military dependents at a military base.

Endodontic treatment completion following emergency pulpectomy

AIM

Emergency pulpectomy is frequently performed to relieve pain experienced by patients following acute episodes of endodontic pain, or to limit the risks of infection or possible root resorption following traumatic pulpal exposures. The aim of this study was to examine subsequent patient attendance for completion of root canal treatment following pulpectomy procedures in a dental emergency unit.

METHODS

The treatment records of 574 patients who had each received an emergency pulpectomy at the Casualty Clinic of the University Dental School and Hospital, Cork, Ireland were reviewed. The influence of age, gender, etiology, tooth type, and month in which the pulpectomy was performed on subsequent completion of endodontic treatment was examined.

RESULTS

Of 574 patients, 39% (n = 224) returned to have endodontic treatment completed, 11% (n = 63) returned to have the tooth extracted, and 50% (n = 287) did not return for completion of the endodontic treatment. Cases were monitored up to five years following pulpectomy. Using a multinomial regression model, tooth type, etiology, and month in which the treatment was performed were found to be statistically significant predictors (p < 0.05) of endodontic treatment completion in the Cork University Dental School and Hospital.

CONCLUSIONS

Proper patient selection and pre-treatment counseling are important considerations when planning emergency pulpectomies to avoid inappropriate use of resources and manpower.

Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care

The aims of this retrospective observational study were to determine the factors which affect treatment provision and the Median Survival Time (MST) for maintenance of tooth vitality following complicated crown fracture. The survey was carried out for patients treated at Newcastle Dental Hospital (NDH) according to departmental guidelines over a 2-year period following the introduction of a new protocol for management of these types of injuries. Seventy-three cases of complicated crown fracture were identified in 69 children with a mean age of 10.3 years (SD = 2.5 years). Seventy-one percent of the fractures occurred in males (M:F ratio was 2.5:1). Fifty-one percent of the complicated crown fractures were in immature teeth. Of the 73 traumatised teeth, 45% presented initially in general dental practice (GDP), 37% at the dental hospital and 8% at local accident and emergency departments with the remaining 10% seen at other or unrecorded locations. Of the 41 fractures, which presented initially at a location other than the dental hospital, 38% were referred to the dental hospital without the provision of an emergency pulp bandage. The overall definitive treatments provided for the 37 open apex teeth included pulp cap (19%), partial pulpotomy (32%), cervical pulpotomy (8%) and pulpectomy (35%), while for the 36 closed apex teeth it was pulp cap (28%), pulpotomy (11%), and pulpectomy (61%). Of the 30 teeth, which underwent vital pulp therapy (18 open and 12 closed apex), the MST for the 15 teeth treated with pulp caps was 1460 days (95% CI: 1067, 1853) while for the 15 teeth treated with pulpotomies it was 1375 days (95% CI: 964, 1786). There was no statistically significant difference in the MST between teeth treated with pulp caps and pulpotomies. In conclusion, the proportion of patients referred to secondary care with complicated crown fractures without provision of a pulp bandage is of some concern. More conservative treatment of closed apex teeth sustaining complicated crown fractures, utilizing vital pulp therapy techniques would appear to be appropriate.

Long-term effect of different treatment modalities for traumatized primary incisors presenting dark coronal discoloration with no other signs of injury

The aim was to compare the long-term outcomes of root canal treatment with that of follow-up-only in traumatized primary incisors in which dark discoloration is the only sign of injury. Root canal treatment was performed in 48 dark discolored asymptomatic primary incisors following trauma. Twenty-five of them [root canal treatment (RCT) group] were followed till eruption of their permanent successors. Ninety-seven dark discolored asymptomatic primary incisors were left untreated and invited for periodic clinical and radiographic examination. Of these, 28 [follow-up (FU) group] were followed till eruption of their permanent successors. The parameters examined included early extraction of the traumatized primary incisor, early or delayed eruption of the permanent successors, ectopic eruption of the permanent successor and signs of enamel hypopcalcification or hypoplasia in the permanent successor. Chi-square test was used for statistical analysis. Seven of 25 (28%) of the RCT group and 32% (nine of 28) of the FU group required early extraction. Five of 25 (20%) of the RCT group and 21% (six of 28) of the FU group showed early or delayed eruption of the permanent successors. Sixteen of 25 (64%) of the RCT group and 79% (22 of 28) of the FU group showed ectopic eruption of the permanent successors. Enamel hypopcalcification or hypoplasia in the permanent successors was equally found (36%) in both groups (nine of 25 in the RCT group and 10 of 28 in the FU group). None of differences was statistically significant. Root canal treatment of primary incisors that had change their color into a dark-gray hue following trauma with no other clinical or radiographic symptom is not necessary as it does not result in better outcomes in the primary teeth and their permanent successors.

Clinical investigation of traumatic injuries in Yeditepe University, Turkey during the last 3 years

The aim of this study was to evaluate etiology, types of traumatic dental injuries, treatment and to determine the incidence of complications according to dental injuries in patients who referred to Yeditepe University, Faculty of Dentistry, Istanbul, Turkey. The study was based on the clinical data of the 161 traumatized teeth in 92 patients. WHO classification slightly modified by Andreasen & Andreasen for dental trauma was used. The causes and localization of trauma, traumatized teeth classification, treatment and complications were evaluated both primary and permanent teeth. The distribution of complications according to diagnosis and treatment of the injured teeth were evaluated. Of 35 (38%) girls and 56 (72%) boys with a mean age 7.6 +/- 3.5 (ranging 1-14.2) participated to study and the mean followed up was 1.72 +/- 1.28 years (ranging 0.10-3.8 years). From the 161 affected teeth, 69 (42.9%) were in primary teeth and 92 (57.1%) in permanent teeth. The highest frequency of trauma occurred in the 6-12 year age group. Overall boys significantly outnumbered girls by approximately 1:1.6. The most common type of injury in the primary and permanent teeth was seen as luxation (38%) and enamel fracture (20%) of the maxillary central incisors, respectively. Falls were the major sources of trauma both the primary (90%) and the permanent teeth (84%). In the primary dentition, the most common type of soft tissue injury is contusion (62.5%) and in the permanent dentition, it is laceration (49%). The most of the treatment choice was determined as examination only and extraction in primary teeth (58 and 24.6%, respectively) while it was applied as restoration and pulpectomy in permanent teeth (31.5 and 18.5%, respectively). Complications were recorded on 37 teeth (23%) with a most common type of necrosis (10.5%) and dental abscess (7.4%). Necrosis was more frequent in luxation whereas dental abscess were in crown fracture with pulpal involvement in both dentitions. The study showed that boys were more prone to dental traumas than girls. Falls were more frequent trauma type with a high complication risk. It reveals that the time of the immediate treatment showed the important predisposing factors that increase the success of treatment and decrease the risk of complication. The correct diagnosis of dental injuries is more important for eliminating the occurrence of complications.

Pediatric dental procedures under general anesthesia at the Amiri Hospital in Kuwait

Ninety-six patients, fifty-eight healthy patients and thirty-eight special needs patients, ranging in age from 3 to 31 yr (average age 6.9 yr) had received dental treatments under general anesthesia (GA) at Amiri Hospital. The mean number of dental procedures per child was 13.6 (SD+/-5.4) with a mean number of 15.6 procedures for healthy patients and 10.5 special needs patients. There was a statistically significantly higher number of dental procedures for healthy patients than for special needs patients (p<0.001). The number of pulpotomies and stainless steel crowns placed for healthy patients was significantly higher (3.5) than for special needs patients (1.3) with (p<0.001) The average number of extractions was similar for the two groups of patients, 2.8 for normal and 2.2 for handicapped. On the basis of these results, it was concluded that dental treatment under GA in hospital environment is beneficial for certain group of patients, such as very young children and those with special needs. Underlying medical conditions influenced the treatment provided.

Comparison of ferric sulfate, formocresol, and a combination of ferric sulfate/formocresol in primary tooth vital pulpotomies: a retrospective radiographic survey

Studies have suggested that formocresol has toxic and carcinogenic potential. A search for an alternative medicament for primary tooth pulpotomies has led to ferric sulfate as a possible alternative. A retrospective study was done in a multipractitioner IHS (Indian Health Service) clinic. Radiographic success or failure was determined for 202 primary tooth pulpotomies performed with either formocresol, ferric sulfate, or a combination procedure of formocresol and ferric sulfate. The post-operative period for the pulpotomies ranged from one month to thirty-six plus months. There was no statistical difference in radiographic failure rates between formocresol, ferric sulfate, or the combination procedure when results were analyzed regardless of post-op period. However, when post-op periods were considered, formocresol performed better at > 36 months and the combination procedure showed significantly more failures at > 36 months.

Safety of dental treatment in patients with previously diagnosed acute myocardial infarction or unstable angina pectoris

OBJECTIVE

The purpose of this study was to assess the safety of invasive dental treatments, such as tooth extraction and pulpectomy under local anesthesia, in patients with unstable angina pectoris and within 6 months after onset in patients who had experienced acute myocardial infarction.

STUDY DESIGN

Cardiovascular complications during and after dental treatment and preoperative risk factors were explored in 63 patients who had experienced unstable angina pectoris or acute myocardial infarction.

RESULTS

A total of 79 dental treatments were performed with no intraoperative complications. Chest pain occurred in 8 patients within 1 week after dental treatment. Risk factors for postoperative complications were identified as a history of chest pain within 2 weeks before the dental treatment and failure to clear the Master Test Single stress test.

CONCLUSIONS

Many patients who had experienced unstable angina pectoris or acute myocardial infarction tolerated dental treatment when appropriate stress control measures were used. However, approximately 10% of the patients experienced postoperative problems. Acceptability of dental treatment should be determined on the basis of the comprehensive assessment of each patient.

Treatment trends during a thirteen-year period in a student pediatric dentistry clinic

This manuscript reports the treatment trends in a pediatric dentistry clinic from 1980 to 1992 and discusses their implication in clinical teaching. Analysis of the records of the senior year pediatric dentistry students indicated: no significant change with time in the patients/student ratio, the number of preformed crowns, pulpotomies, and pulpectomies by student or by patient; a significant decrease in the number of one-surface and > or = 2-surface restorations by student and by patient; a significant increase in the number of pit-and-fissure sealants and preventive resin restorations by student and by patient. During the thirteen-year period, the students performed an average of 7.3 one-surface; 12.9 > or = 2-surface restorations; 5.5 preformed crowns; 6.4 pit-and-fissure sealants; 2.4 pulpotomies. There was a significant increase with time in the number of students who performed pit-and-fissure sealants.

Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States

A survey of all predoctoral pediatric dental programs in the United States was conducted to ascertain the contemporary teaching philosophies and techniques for pulp therapy in primary teeth. All 53 predoctoral programs responded to a two-part survey consisting of multiple choice questions regarding which pulp therapies and specific techniques were taught and which pulp therapies would be employed under certain hypothetical clinical scenarios. The results of the survey confirmed some lack of consensus on the selection and application of certain treatment modalities and techniques taught for primary tooth pulp therapy in predoctoral dental programs in the United States.

Postoperative pain incidence related to the type of emergency treatment of symptomatic pulpitis

Some endodontic emergencies occur as a result of attempts to relieve symptoms of pulpitis. The aim of this study was to identify any predictor of postoperative pain in a patient population treated by dental students. Patients who reported for treatment of symptomatic pulpitis were subjected to three different emergency treatment regimens. Clinical data was collected on those patients who reported in the emergency service with severe postoperative pain within 24 hours of emergency endodontic treatment. Statistical analysis of these data suggested that the type of endodontic emergency procedure carried out was a significant predictor of severe postoperative pain.