The Endodontic Complexity Assessment Tool (E-CAT): A digital form for assessing root canal treatment case difficulty

AIMS

To develop an evidence-based, valid and reliable assessment tool that educational establishments and dental practitioners may use to assess the complexity of root canal treatment (RCT) utilizing digital advancements. The study also aimed to provide a more objective definition of the term 'uncomplicated' root canal treatment as described by the Association for Dental Education in Europe (ADEE) and the European Society of Endodontology (ESE) undergraduate curriculum guidelines for Endodontology.

METHODOLOGY

The development process involved a narrative review of the literature to identify the complexity factors associated with root canal treatment on permanent teeth; an iterative development and analysis process to assess the weighting of these factors; and the programming of digital software to enhance the efficiency and user interface of the assessment form. Validation of the tool was sought with a panel of 35 specialist endodontists to assess clinical scenarios and assess the consensus inter-examiner agreement with the outcomes provided by the E-CAT. The inter-user and intra-user reliability studies were conducted with 15 dentists to evaluate the same clinical cases and by repeating the experiment 9 months later. The ease of use of the form was also assessed.

RESULTS

The E-CAT was successfully developed with a total of 19 complexity criteria and hosted on a secure server under the domain of www.e-cat.uk. The tool provides a smart interactive filtering mechanism and automatic background calculation of the risk scores. Three levels of complexity were defined: class I (uncomplicated), class II (moderately complicated) and class III (highly complicated). The consensus of the panel of endodontists had excellent agreement with the outcome of the E-CAT. The inter-user and intra-user reliability was found to be 0.80 and 0.90, respectively. The average time to assess a case was 1:36 min.

CONCLUSION

The E-CAT gave promising results providing an efficient and reliable platform to assess the complexity of cases undergoing root canal treatments. The study design allowed the formulation of a more objective definition to describe 'uncomplicated' root canal treatment as referred to by the ESE and ADEE guidelines. This study is advantageous for educational, public health and referral pathways.

Evidence for programmed odontoblast process retraction after dentine exposure in the rat incisor

OBJECTIVE

To re-examine the morphology and potential functions of odontoblasts in intact rat incisors and after cavity preparation into dentine.

DESIGN

Intact incisors were fixed, decalcified, snap frozen and sectioned (10μm), before staining with rhodamine phalloidin or antibodies for cyto-skeletal proteins: vimentin and actin, ion transporter: NaK-ATPase, and dendritic cell marker: OX6. Samples with cavity were processed similarly and stained for actin and vimentin before comparing the lengths of odontoblast processes (OP) at baseline, 3h and 24h (n=5 for each group).

RESULTS

Actin was expressed through the full length of OP, while vimentin immunoreactivity was not uniform, with 4 distinct regions. OP showed morphological complexity with fine branches emanating within different regions of dentine. Novel actin-positive tree-like OP were identified within predentine which reduced in intensity and length toward the incisal portion of the tooth. Specimens with cavities showed time-dependant pulpal retraction of OP.

CONCLUSIONS

Differences in structural antibody expression suggest functional variations in OP within different regions of dentine. The role of actin positive OP in predentine is not known, but could be related to dentine deposition, cellular stability or sensing mechanisms. Cavity preparation into dentine was followed by programmed retraction of OP which could be controlled either mechanically by the spatial limitation of the OP within dentinal tubules or structurally by the presence of vimentin, in addition to actin, in the mid-dentine.

Factors affecting direction and strength of patient preferences for treatment of molar teeth with nonvital pulps

AIM

To elicit the factors affecting willingness to pay (WTP) values for the preferred options of participants for dealing with a molar tooth with a nonvital pulp, a common but difficult problem.

METHODOLOGY

A total of 503 patients were recruited from dental practices in the North East of England and interviewed. Their preferred treatment option for a molar tooth with a nonvital pulp (endodontics, extraction and various prosthetic restorative options) and WTP for this preferred option were elicited. Factors affecting preferred option and WTP were analysed using econometric modelling.

RESULTS

Overall, 53% of the sample wished to save the tooth with a mean WTP of £373. The variance in WTP was high. Of those opting for extraction, the majority chose to leave a gap or have an implant. The preferred option was influenced by previous treatment experience. WTP was only influenced by having a low income.

CONCLUSIONS

The high level of variance in WTP and its relatively unpredictable nature pose difficult questions for policy makers trying to ensure the delivery of an equitable service. For dentists, it is important not to make assumptions about patient preference and strength of preference when making decisions. Ideally, WTP values should be considered alongside effectiveness data, and those on costs, in policy making.

Effect of massage on the efficacy of the mental and incisive nerve block

The purpose of this trial was to assess the effect of soft tissue massage on the efficacy of the mental and incisive nerve block (MINB). Thirty-eight volunteers received MINB of 2.2 mL of 2% lidocaine with 1 : 80,000 epinephrine on 2 occasions. At one visit the soft tissue overlying the injection site was massaged for 60 seconds (active treatment). At the other visit the crowns of the mandibular premolar teeth were massaged (control treatment). Order of treatments was randomized. An electronic pulp tester was used to measure pulpal anesthesia in the ipsilateral mandibular first molar, a premolar, and lateral incisor teeth up to 45 minutes following the injection. The efficacy of pulp anesthesia was determined by 2 methods: (a) by quantifying the number of episodes with no response to maximal electronic pulp stimulation after each treatment, and (b) by quantifying the number of volunteers with no response to maximal pulp stimulation (80 reading) on 2 or more consecutive tests, termed anesthetic success. Data were analyzed by McNemar, Mann-Whitney, and paired-samples t tests. Anesthetic success was 52.6% for active and 42.1% for control treatment for lateral incisors, 89.5 and 86.8% respectively for premolars, and 50.0 and 42.1% respectively for first molars (P = .344, 1.0, and .508 respectively). There were no significant differences in the number of episodes of negative response to maximum pulp tester stimulation between active and control massage. A total of 131 episodes were recorded after both active and control massage in lateral incisors (McNemar test, P = 1.0), 329 (active) versus 316 (control) episodes in the premolars (McNemar test, P = .344), and 119 (active) versus 109 (control) episodes respectively for first molars (McNemar test, P = .444). Speed of anesthetic onset and discomfort did not differ between treatments. We concluded that soft tissue massage after MINB does not influence anesthetic efficacy.

The efficacy of infiltration anaesthesia for adult mandibular incisors: a randomised double-blind cross-over trial comparing articaine and lidocaine buccal and buccal plus lingual infiltrations

AIM

To compare the efficacy of 2% lidocaine and 4% articaine both with 1:100,000 adrenaline in anaesthetising the pulps of mandibular incisors.

METHODS

Thirty-one healthy adult volunteers received the following local anaesthetic regimens adjacent to a mandibular central incisor: 1) buccal infiltration of 1.8 mL lidocaine plus dummy lingual injection (LB), 2) buccal plus lingual infiltrations of 0.9 mL lidocaine (LBL), 3) buccal infiltration of 1.8 mL articaine plus dummy lingual injection (AB), 4) buccal plus lingual infiltrations of 0.9 mL articaine (ABL). Pulp sensitivities of the central incisor and contralateral lateral incisor were assessed electronically. Anaesthetic efficacy was determined by two methods: 1) Recording the number of episodes with no responses to maximal electronic pulp tester stimulation during the course of the study period, 2) recording the number of volunteers with no response to maximal pulp tester stimulation within 15 min and maintained for 45 min (defined as sustained anaesthesia). Data were analysed by McNemar, chi-square, Mann-Whitney and paired t-tests.

RESULTS

For both test teeth, the number of episodes of no sensation on maximal stimulation was significantly greater after articaine than lidocaine for both techniques. The split buccal plus lingual dose was more effective than the buccal injection alone for both solutions (p <0.001). 4% articaine was more effective than 2% lidocaine when comparing sustained anaesthesia in both teeth for each technique (p <0.001), however, there was no difference in sustained anaesthesia between techniques for either tooth or solution.

CONCLUSIONS

4% articaine was more effective than 2% lidocaine (both with 1:100,000 adrenaline) in anaesthetising the pulps of lower incisor teeth after buccal or buccal plus lingual infiltrations.

Parallel post-space preparation in different tooth types ex vivo: deviation from the canal centre and remaining dentine thickness

AIM

To determine the deviation of parallel-sided twist-drills during post-channel preparation and relate this to tooth type and position.

METHODOLOGY

Human teeth with single root canals were selected: maxillary second premolars (group i); maxillary lateral incisors (group ii); mandibular canines (group iii); mandibular first premolars (group iv; all groups n = 16). The teeth were reduced to 17 mm length by sectioning the crown, and the root canals prepared and filled. Microradiographs were made in two directions. The teeth were individually embedded in a gypsum jaw and placed in a phantom head. Two operators performed parallel post-space preparation (12 mm length, 1.25 mm diameter) to the following protocol: gutta-percha removal with Gates Glidden drills numbers 2 and 3 and post-space enlargement with parallel drills numbers 3, 4 and 5, consecutively. Subsequently, microradiographs were re-exposed. The original and post-operative microradiographs were digitized and superimposed, and deviation of the post-space from the filled canal and remaining dentine thickness measured.

RESULTS

Overall, the mean deviation was 0.07 mm to the mesial (95% CI: 0.01-0.12), and 0.27 mm to the buccal (95% CI: 0.18-0.35). Group ii had significantly more buccal deviation than other groups (P = 0.004-0.008). A remaining dentine thickness of <0.5 mm occurred 16 times in 14 teeth, and of <1 mm occurred 97 times in 52 teeth.

CONCLUSIONS

Deviation during parallel post-preparation was common, predominantly in mesial and buccal directions, especially in maxillary incisors. This deviation increased the risk of perforation considerably.

Influence of Injection Speed on the Effectiveness of Incisive/Mental Nerve Block: A Randomized, Controlled, Double-blind Study in Adult Volunteers

This randomized, double-blind trial tested the null hypothesis that speed of deposition has no influence on the injection discomfort, efficacy, distribution, and duration of pulp anesthesia after incisive/mental nerve block in adult volunteers. Thirty-eight subjects received incisive/mental nerve blocks of 2.0 mL lidocaine with 1:80,000 epinephrine slowly over 60 seconds or rapidly over 15 seconds at least 1 week apart. Pulp anesthesia was assessed electronically to 45 minutes after injection. Injection discomfort was self-recorded on visual analogue scales. Overall, 48.7% of volunteers developed pulp anesthesia in first molars, 81.8% in bicuspids, and 38.5% in lateral incisors. The mean duration of pulp anesthesia was 19.1 minutes for first molars, 28.5 minutes for bicuspids, and 19.0 minutes for lateral incisors. Speed of injection had no significant influence on anesthetic success or duration of anesthesia for individual teeth. Slow injection was significantly more comfortable than rapid injection (P < .001). The null hypothesis was supported, although slow injection was more comfortable.

Tutor perceptions of the use of a reflective portfolio within a pastoral tutor system to facilitate undergraduate personal development planning

All Higher Education Institutions in the UK are now required to provide transcripts of student activity and outcomes of summative assessments. In addition, the student should be able to reflect on their learning and plan their own development. This article reports on the staff evaluation of the use of a reflective portfolio facilitating the production of highly individualised personal development plans within an existing tutor system. A number of significant issues are highlighted; tutor systems adopting this approach must maintain flexibility for managing student crises when they arise, the difference between appraisal and assessment needs clear definition for both students and tutors, training in basic mentoring skills should be provided for all tutors, tutors should be aware of the difficulties many students experience with reflection and also be alert to the over reflective learner.

Pulpal anaesthesia for mandibular permanent first molar teeth: a double-blind randomized cross-over trial comparing buccal and buccal plus lingual infiltration injections in volunteers

AIM

To compare the efficacy of buccal and buccal plus lingual infiltration anaesthesia for permanent mandibular first molars.

METHODOLOGY

Thirty one healthy adult volunteers received each of the following methods of anaesthesia for a mandibular first molar tooth in a randomised order, 1) Buccal infiltration of 1.8 mL and needle penetration lingually. 2) Buccal infiltration of 0.9 mL, plus lingual infiltration of 0.9 mL. Two percent lidocaine with 1:100,000 epinephrine was used. Electrical pulp testing was performed before, and every 2 minutes for 30 minutes after injection. A successful outcome was recorded as the absence of pulp sensation on two or more consecutive maximal pulp tester stimulations (80 microA). Injection discomfort was assessed using visual analogue scales. Data were compared with McNemar and Wilcoxon Signed Ranks tests.

RESULTS

Buccal infiltration was successful in 38.7% of cases compared to 32.3% after combined infiltrations; the difference was not significant (P = 0.63). Buccal infiltration produced more episodes of no response to maximum stimulation than buccal and lingual infiltrations (129 and 114 respectively), this difference was not significant (P = 0.11). Peak anaesthetic effect occurred around 10-14 minutes after injection. There was no difference in injection discomfort between buccal injections of 0.9 mL and 1.8 mL of solution (P = 0.90). Lingual injection was more uncomfortable than lingual penetration (P = O.O02).

CONCLUSIONS

Buccal and buccal plus lingual infiltrations did not differ in their efficacy in producing anaesthesia of permanent first molar teeth.

Speed of Injection Influences Efficacy of Inferior Alveolar Nerve Blocks: A Double-Blind Randomized Controlled Trial in Volunteers

This randomized double-blind crossover trial investigated the efficacy and discomfort associated with slow (60 seconds) and rapid (15 seconds) inferior alveolar nerve blocks (IANB) using 2.0 ml of 2% lidocaine with 1:80,000 epinephrine in securing mandibular first molar, premolar and lateral incisor pulp anesthesia in 38 healthy adult volunteers. Episodes of maximal stimulation (80 microA) without sensation on electronic pulp testing were recorded. Injection discomfort was self-recorded by volunteers on 100 mm visual analogue scales. Data were analyzed by McNemar, Friedman, Wilcoxon Signed Ranks, and paired t tests. Slow IANB produced more episodes of no response to maximal pulp stimulation than rapid IANB in molars (220 episodes versus 159, p < 0.001), premolars (253 episodes versus 216, p = 0.003) and lateral incisors (119 episodes versus 99, p = 0.049). Slow IANB was more comfortable than rapid IANB (p = 0.021).

Articaine and Lidocaine Mandibular Buccal Infiltration Anesthesia: A Prospective Randomized Double-Blind Cross-Over Study

This randomized crossover double-blind trial compared the efficacy of buccal infiltration with 4% articaine and 2% lidocaine (both with 1:100,000 epinephrine) in securing mandibular first molar pulp anesthesia. Injections were given at least 1 week apart in 31 healthy adult volunteers. Electronic pulp testing was undertaken at baseline and at 2 minute intervals until 30 minutes postinjection. A successful outcome was recorded in the absence of pulp sensation on two consecutive maximal pulp tester stimulations (80 muA). 64.5% of articaine and 38.7% of lidocaine infiltrations were successful (p = 0.008). Articaine infiltration produced significantly more episodes of no response to maximum stimulation in first molars than lidocaine (236 and 129, respectively, p < 0.001). Mandibular buccal infiltration is more effective with 4% articaine with epinephrine compared to 2% lidocaine with epinephrine. Both injections were associated with mild discomfort.

The role of nurses in telemedicine and child abuse

Telemedicine allowed for imaging and videoconferencing between staff at a medical center hub and registered nurses who performed child abuse examinations at community hospitals. By means of electronic communication and information technology, a network was designed to facilitate the examination of children at distant locations when abuse was suspected. Telemedicine provided for expert consultation, rapid evaluation, response to community needs, and an expanded role for nurses. This anecdotal evaluation explored the experience from the view of the registered nurses and an advanced registered nurse practitioner who participated in the telemedicine network. Findings indicated that nurses went through phases of adjustments while becoming familiar with the information technology, cameras, and setup while focusing on the needs of the children and their own responses. Telemedicine nurses were able to draw upon their clinical backgrounds in caring for children and apply their knowledge and skills when assessing victims of abuse. On the basis of interviews and observation, it was concluded that telecommunication did not interfere with the nurse-patient relationship.

CarisolvTM: an alternative to NaOCl in immature root canals?

AIM

To test the null hypothesis that Carisolv is no more effective than 1% sodium hypochlorite in cleaning uninstrumented, immature root canals.

METHODOLOGY

A total of 240 uniform, immature ovine incisors were decoronated at the CEJ level and randomly divided into four groups of 60. After gross pulp extirpation, canals were flooded with normal saline (negative control), 1% NaOCl, Carisolv or 5% NaOCl (positive control) and incubated for 10 min (group 1), 20 min (group 2), 30 min (group 3) or 30 min, refreshing irrigant at 10 and 20 min (group 4). SEM photomicrographs of canal wall debris in the apical, middle and coronal thirds were scored against a 5-point scale. Internal consistency was assessed by kappa statistics. Debris scores for different irrigant regimes at different canal levels were analysed by non-parametric tests (P < 0.05).

RESULTS

Canals were consistently cleaner in the coronal and middle than apical thirds. NaOCl (5%) was consistently most effective. Carisolv and NaOCl (1%) were no more effective than normal saline in group 1 (P > 0.05), but significantly more effective than normal saline in groups 2 (middle and apical 1/3), 3 and 4 (P < 0.05). Carisolv and NaOCl (1%) had comparable activity in groups 1, 2 (middle and apical thirds) and 3, but NaOCl (1%) was significantly more effective than Carisolv in group 4 (coronal and middle thirds).

CONCLUSIONS

1. The ovine incisor model presents opportunities to investigate irrigation regimes under controlled ex-vivo conditions. 2.NaOCl (5%) remains the most effective irrigant for rapid debris removal in immature root canals. 3. Carisolv cleans pulp debris from the walls of immature root canals as effectively as NaOCl (1%) during static, unrefreshed wall contact for between 20 and 30 min. 4. Refreshment of NaOCl (1%) enhances its cleaning ability above that of Carisolv.

Pressures generated in vitro during Stabident intraosseous injections

AIM

To test the hypothesis that the Stabident intraosseous injection is a potentially high-pressure technique, which carries serious risks of anaesthetic cartridge failure.

METHODOLOGY

A standard Astra dental syringe was modified to measure the internal pressure of local anaesthetic cartridges during injection. Intra-cartridge pressures were measured at 1 s intervals during slow (approximately 15 s) and rapid (<10 s) injections of 2% Xylocaine with 1:80,000 adrenaline (0.25 cartridge volumes) into air (no tissue resistance), or into freshly prepared Stabident perforation sites in the anterior mandible of freshly culled young and old sheep (against tissue resistance). Each injection was repeated 10 times over 3 days. Absolute maximum pressures generated by each category of injection, mean pressures at 1 s intervals in each series of injections, and standard deviations were calculated. Curves of mean maximum intra-cartridge pressure development with time were plotted for slow and rapid injections, and one-way anova (P<0.05) conducted to determine significant differences between categories of injection.

RESULTS

Pressures created when injecting into air were less than those needed to inject into tissue (P<0.001). Fast injection produced greater intra-cartridge pressures than slow delivery (P<0.05). Injection pressures rose more quickly and to higher levels in small, young sheep mandibles than in larger, old sheep mandibles. The absolute maximum intra-cartridge pressure developed during the study was 3.31 MPa which is less than that needed to fracture glass cartridges.

CONCLUSIONS

Stabident intraosseous injection conducted in accordance with the manufacturer's instructions does not present a serious risk of dangerous pressure build-up in local anaesthetic cartridges.

Endodontic complications after plastic restorations in general practice

AIM

To test the hypothesis that dentine and pulp protection by conditioning-and-sealing is no less effective than using a conventional calcium hydroxide lining.

METHODOLOGY

A cohort of healthy adults requiring a new or replacement restoration in a posterior tooth was recruited in six general practices. All procedures received local Ethics Committee approval. Exclusion criteria included signs and symptoms of pulp necrosis or inflammation, and patients unable to commit to a long-term trial. Cavity preparations were randomized to receive a calcium hydroxide lining or conditioning-and-sealing with a smear-removing bonding system. Choice of bulk restorative material (composite resin or amalgam) was at the discretion of the dentist. The key outcome measure was evidence of pulpal breakdown identified at unscheduled (emergency) or scheduled recall examinations. Postoperative sensitivity was recorded on 100 mm VAS at 24 h, 4 days and 7 days. Pulp status was assessed at 6, 12, 24 and 36 month recall, and at any emergency recall appointment. The relationship between pre-treatment and treatment variables and pulp breakdown was assessed by logistic regression (P = 0.05).

RESULTS

A total of 602 teeth were recruited, with comparable numbers of cavities lined (288, 47.8%) or conditioned and sealed (314, 52.2%). The majority (492, 81.7%) were replacement restorations, and amalgam was the most common bulk restorative material (377, 62.6%). A total of 390 (64.8%) restored teeth were reviewed at 6 months, 307 (51%) at 12 months, 363 (60.3%) at 24 months, and 279 (46.3%) at 36 months post-restoration. Sixteen cases of pulp breakdown were identified within 36 months of restoration placement, 11 presenting as emergencies and five detected at routine recall examination. Logistic regression showed that preoperative pain, cavity treatment by lining or conditioning-and-sealing and the use of rubber dam isolation had no association with pulp breakdown. Pulp breakdown was associated with deep or pulpally exposed cavities (P < 0.001, odds ratio 7.8) and with composite rather than amalgam restorations (P = 0.001, odds ratio 2.13). Re-coding to identify teeth with pulp exposures revealed that pulpal exposure was the key determinant of adverse pulp outcomes (P < 0.0001, odds ratio 28.4) and that composite resin restorations were again more likely to be associated with pulp breakdown than amalgam (P = 0.017, odds ratio 3.92).

CONCLUSIONS

Considered within the context of routine primary dental care: Dentists can be confident that pulps will be equally well protected from post-restorative breakdown up to 36 months by calcium hydroxide lining and conditioning-and-sealing with adhesive resins. Residual dentine thickness appears to be a key determinant of pulp responses after restorative dental treatment. In deep and pulpally exposed cavities in posterior teeth, composites were associated with more pulpal breakdown than amalgams.

Coronal Leakage of Sealer-Only Backfill: An In Vitro Evaluation

We tested the hypothesis that AH Plus and Roeko Seal Automix (RSA) sealers alone are no less effective in preventing coronal microleakage than gutta-percha compacted with sealer. Freshly prepared sheep incisor root canals were obturated with warm gutta-percha alone, AHPlus or RSA alone, or warm gutta-percha with AH Plus or RSA (n = 20 each group). Coronal leakage was assessed under vacuum conditions with Indian ink and tooth clearing. Sealer-only backfills with AH Plus and RSA yielded significantly more dye-free canals than backfills of gutta-percha alone or with sealer (p < 0.001). Warm gutta-percha with or without sealer kept no more canals sealer free than the positive control. Mean dye penetration was 0.92% of canal length for AH Plus and RSA backfills, 27.42% for gutta-percha only backfills, 26.47% for gutta-percha with RSA and 13.92% for gutta-percha with AH Plus. Sealer only backfills allowed significantly less leakage than those including warm gutta-percha (p < 0.001). Sealer-only backfills may be a viable alternative to traditional gutta-percha and sealer compaction methods.

Crowns and extra-coronal restorations: endodontic considerations: the pulp, the root-treated tooth and the crown

Endodontic considerations is the fourth in the series on crowns and other extra-coronal restorations. This article focuses strongly on contemporary biological principles, and is not intended to provide a comprehensive review of commercially available materials and techniques. Principles are illustrated in a variety of clinical case scenarios.

Antibiotic prophylaxis for patients with joint prostheses - still a dilemma for dental practitioners

OBJECTIVES

To provide a critical review of the current evidence that implicates dental-induced bacteraemia as a risk for joint infections in patients fitted with joint prostheses and appraise the need for antibiotic prophylaxis.

DESIGN

Retrospective analysis.

SETTING

Mainly hospital-based patients or subjects.

OUTCOME MEASURES

The relationship between joint infections and dental treatment is equivocal at the best and there is no evidence that antibiotic prophylaxis provides such patients with any protection.

RESULTS

Microbiological evidence linking dental treatment-induced bacteraemia to joint infections is weak and if an oral commensal is implicated, it is more likely to have arisen either from a spontaneous bacteraemia or from a dental infection. As a consequence of the latter, we recommended the institution of good dental health prior to joint replacement. There may be a case for providing prophylaxis to the immuno-compromised patient, but only if the immuno-suppression is associated with a neutropenia. In such circumstances, only emergency treatment should be considered until the neutropenia is resolved. Antibiotic regimens that are recommended by orthopaedic surgeons have not been evaluated in a randomised placebo-controlled study and many of the drugs are not licensed for this purpose. The evidence on cost-risk benefit seems to demonstrate that antibiotic prophylaxis with either amoxicillin or penicillin is not cost effective when compared with no prophylaxis.

CONCLUSION

The case for providing antibiotic prophylaxis prior to dental treatment in patients fitted with a joint prosthesis is weak or virtually non-existent. Furthermore, the risk from providing prophylaxis is greater than the risk of a joint infection.

Preliminary in vitro evaluation of Carisolv as a root canal irrigant

AIM

To test the null hypothesis that Carisolv is no better than PBS in removing organic debris from uninstrumented root canals.

METHODOLOGY

The pulps of two uniform groups of 36 immature, sheep mandibular incisors were grossly removed with barbed broaches immediately prior to the study. Roots in group 1 were irrigated with phosphate buffered saline (PBS), strong sodium hypochlorite (4.5%) or Carisolv without ultrasonic agitation, whilst in group 2 the same irrigants were activated with ultrasound. Canal walls were exposed to irrigants for 10, 20 or 30 min at 37 degree C. In group 2, ultrasound was applied for 30 s at 2, 5 and 7 min within each 10 min incubation period. After washing irrigants free and immersion in fixative, all teeth were split longitudinally, critical point dried and sputter coated for SEM analysis. SEM photomicrographs were recorded of representative areas in the coronal, middle and apical canal thirds and debris scored by a single assessor against a five-point scale. Intraobserver reliability was assessed by Cohens kappa scores and debris scores analysed by the non-parametric Kruskal-Wallis test at P < 0.05.

RESULTS

Sodium hypochlorite was significantly better than Carisolv and PBS in cleaning root canals (P < 0.0001), whether or not ultrasound was applied. Carisolv was shown to clean canals better than PBS, again whether or not ultrasound was applied (P = 0.01). Both incubation time and ultrasound enhanced the action of Carisolv (P < 0.001) whilst the activity of PBS was not significantly improved by exposure time or the application of ultrasound. Kappa scores of 0.90-0.95 indicated excellent consistency in debris scoring.

CONCLUSIONS

Within the limitations of this preliminary study (i). Carisolv cleaned root canals better than PBS and shows promise as an adjunct to root canal preparation; (ii). the action of Carisolv was enhanced by incubation times beyond 20 min whether or not ultrasound was applied; (iii). sodium hypochlorite solution remains the gold standard endodontic irrigant, provided that it is used with care and is contained in the canal system.

Prostaglandin E2 and treatment outcome in pulp therapy of primary molars with carious exposures

OBJECTIVES

Prostaglandin E2 (PGE2) has been suggested as an indicator of irreversible pulpitis in permanent teeth [1]. There is scant information on the role of chemical mediators in primary molar pulp inflammation. The aim of this preliminary study was to investigate the levels of PGE2 in blood harvested from root pulp stumps following coronal pulp amputation in vital primary molar teeth with carious exposures.

METHODS

Seventy-nine cariously exposed primary molars underwent treatment by one of two vital pulp therapy techniques. Blood was harvested from 38 teeth and volume and concentration of PGE2 ([PGE2]) determined [2]. Treatment outcome was assessed from both clinical and radiographic evidence.

RESULTS

PGE2 was detected in all samples, with a wide concentration range (1-2641 ng/mL). The distribution was skewed, requiring log transformation. The difference in the mean (log) [PGE2] for radiological success (3.12, SD 1.60 and failure (4.62, SD 1.80) was significant, t = 2.05, P = 0.047. The difference in the mean (log) [PGE2] for clinical success (3.24, SD 1.65) and failure (5.44, SD 1.43 was near-significant, t = 1.84, P = 0.074.

CONCLUSION

[PGE2] correlated positively with radiological outcome following vital pulp therapy.

Design and implementation of an urban/rural Telehealth Network for the Evaluation of Abused Children: implications for global primary care applications

To meet the increasing need for rapid medical evaluation of allegations of child abuse in rural areas and the paucity of trained professionals to provide these evaluations, a model telemedicine network was designed and implemented initially in the State of Florida, USA. The utilization of various types of equipment, transmission modes, and electronic peripherals, will be discussed, as well as utilization of physician extenders for assessment. The expansion of this system for other medical uses will be summarized. Experiences in replication of the model in a southern Alabama rural county will be detailed.

State programs for medical diagnosis of child abuse and neglect: case studies of five established or fledgling programs

OBJECTIVE

To describe the programs for medical diagnosis of child abuse and neglect in three states and efforts to establish state-wide programs in two states. To describe common themes and issues that emerged related to the establishment and maintenance of these programs.

METHODS

Five states were selected as case studies to represent a range of experience and type of function embodied in programs that address medical diagnosis of child abuse and neglect. Individuals knowledgeable about the programs or efforts to establish state-wide programs in their home states described these in detail. Inductive analysis was used to identify themes and issues that emerged across the states studied.

FINDINGS

Themes emerged in three general areas: funding, services, and training. Findings related to funding were: 1) State funding was vital for initiation of statewide programs; 2) Alliances with other groups with parallel interests were successfully used to garner support for child abuse programs; 3) Services needed to be adequately reimbursed to be sustained; 4) Political climate often affected funding. With regard to services we found: 1) There was no optimal way to organize services, but rather many ways that worked well; 2) It was critical to address local service needs; 3) Provision of standardized quality services was essential. With regard to training: 1) Professional training was an integral part of all statewide programs; 2) New technologies, including televideo, have been explored and implemented to assist in training in statewide programs.

CONCLUSIONS

Each state has taken a unique approach to programs for the medical diagnosis of child abuse and neglect. However, there are commonalities, particularly among the states that have been successful in establishing and maintaining comprehensive services and/or training.

Infective endocarditis, dentistry and antibiotic prophylaxis; time for a rethink?

OBJECTIVE

To provide a critical review of the current evidence that links dental treatment to infective endocarditis (IE) and appraise the risks of antibiotic chemoprophylaxis.

DESIGN

Retrospective analysis

SETTING

Mainly hospital based patients or subjects

OUTCOME MEASURES

The interrelationship between infective endocarditis and dental treatment is complex and in many instances uncertain. The risk from antibiotic chemoprophylaxis appear greater than the risk of contracting IE.

RESULTS

There is increasing evidence that spontaneous bacteraemia are more likely to cause IE in at risk patients than specific episodes of dental treatment. Antibiotic chemoprophylaxis may not necessarily reduce dental-induced bacteraemia and the protective effect if any from antibiotic cover may arise from an inhibitory action upon bacterial colonisation on the compromised cardiac valves.

CONCLUSION

There is increasing concern over the misuse of antibiotics in general and this has focused attention on chemoprophylaxis in dentistry to prevent IE. New evidence on dental-induced bacteraemia and the prevalence of IE in association with dental treatment raises further questions on the need to provide antibiotic cover in at risk patients. More prescriptive guidelines to define who is at risk from IE and what procedures require cover will help to reduce overprescribing of antibiotics and reduce the risks of their unwanted effects.

Primary molar pulp therapy--histological evaluation of failure

OBJECTIVES

Qualitative comparison of the clinical, radiographic and histological outcomes in a small sample of cariously exposed primary molars, extracted after unsuccessful pulp treatment by two vital pulpotomy methods.

SUBJECTS AND METHODS

The primary molars were extracted, because of treatment failure, during a longitudinal clinical investigation of the relative efficacy of 20% Buckley's Formocresol versus calcium hydroxide powder as pulp dressings in vital pulp therapy (in press). Fifty-two child patients were sequentially enrolled in the longitudinal clinical investigation, 26 boys and 26 girls. Primary molar teeth requiring vital pulp therapy were randomly allocated to either the formocresol group (F) or the calcium hydroxide group (C). Coronal pulp amputation was prescribed only in teeth with vital, cariously-exposed pulp tissue. All cases were reviewed using predefined clinical and radiological criteria. Seventy-nine cariously-exposed primary molars required vital pulp therapy. Forty-four teeth were included in group F and 35 in group C. Five per cent (n = 2) of teeth in group F and 11 per cent of teeth (n = 4) in group C were terminated from the trial due to clinical and/or radiographic failure. Of the six teeth extracted, five were sufficiently intact to be retained for histological evaluation.

RESULTS

Post-extraction radiographs taken before specimen preparation showed reactionary dentine barrier (bridge) formation in teeth treated with calcium hydroxide. However, the narrowing of root canals, indicative of appositional reactionary dentine deposition, was seen in both groups (F and C). Histological examination confirmed these findings and revealed that pus cells were evident in all specimens examined. There was also histological evidence of resorption of reactionary dentine within the root canal and that forming the calcified barrier (dentine bridge).

CONCLUSION

The clinical and radiographic outcomes for the five teeth correlate well with the reported findings from decalcified histological section. Although numbers are small, the histological findings may indicate possible reasons for treatment failure. There are few reports of this sort in the literature of this under-researched treatment modality.

Use of rubber dam and irrigant selection in UK general dental practice

AIM

To evaluate factors which influence rubber dam use and irrigant selection in UK National Health Service (NHS) endodontics.

METHODOLOGY

A postal survey was conducted amongst two age cohorts of dentists, representing all of the 1970-73 (older) and 1990-93 (younger) graduates of two northern English dental schools (n = 643). Key and supplementary questions were posed on levels of rubber dam use, irrigant selection, and factors influencing practice in NHS endodontics. After manual checking, validated (dual) entry of responses was made to a flat ASCII data file before analysis with SPSS software. The threshold for statistical significance was set at the 95% probability level.

RESULTS

Eighty-five per cent of the valid sample responded to the questionnaire. Regardless of age and qualifying school, less than one-fifth of dentists always or frequently used rubber dam, whilst 60% never used it. Qualifying school had a significant influence on rubber dam use, whilst age had a variable influence. Major disincentives to the use of rubber dam included the perception that patients do not like it, that the NHS fee was inadequate to justify its use, that it took too long to apply, and that dentists had received inadequate training. Frequent users of rubber dam were significantly less likely to cite these disincentives than nonusers. Overall, local anaesthetic solution was the most common endodontic irrigant. Irrigant choice was strongly linked to rubber dam use, and to graduation cohort. Seventy-one per cent of rubber dam users irrigated with sodium hypochlorite, compared with only 38% of nonusers. This pattern was reversed for local anaesthetic irrigation. Younger graduates were significantly more likely to irrigate with local anaesthetic solution than their older counterparts, and the younger graduates of one school showed a highly significant increase in the use of chlorhexidine.

CONCLUSIONS

1) The majority of UK Health Service dentists never use rubber dam isolation in endodontic treatment. 2) Qualifying school has a significant impact on rubber dam use, and irrigant selection. 3) Use of rubber dam has a significant association with irrigant choice in endodontics.

Apparent periapical repair without operative intervention: a case report and discussion

CASE REPORT

A case is described where substantial reduction of an established periapical lesion appeared to take place in the absence of operative intervention, and as the crown of the tooth was progressively destroyed by dental caries. The case raises debate on the pathogenesis, diagnosis and monitoring of endodontic lesions, and may stimulate renewed research interest in these most fundamental elements of clinical endodontology.

An investigation of the relative efficacy of Buckley's Formocresol and calcium hydroxide in primary molar vital pulp therapy

OBJECTIVE

To compare the clinical and radiological outcomes following two different, single visit vital pulp therapy techniques, in cariously exposed primary molar teeth.

SETTING

A paediatric dental clinic within the Dental Hospital, Newcastle upon Tyne, UK.

SUBJECTS

Fifty two child patients were sequentially enrolled in the clinical investigation, 26 males and 26 females with an age range of 3.3-12.5 years. Primary molar teeth requiring vital pulp therapy were randomly allocated to either the formocresol group (F) or the calcium hydroxide group (C). The total number of teeth treated was 84.

DESIGN

Recruitment was on the basis of strict inclusion criteria. Coronal pulp amputation was prescribed only in teeth with vital, cariously exposed pulp tissue. Treatment was undertaken between October 1994 and December 1996. All cases were reviewed using predefined clinical and radiological criteria. The statistical tests used were logistic regression of a triple nested data structure, chi-squared analysis of equality of treatment and probability of success with relation to subject age.

RESULTS

Eighty-four cariously exposed primary molars required vital pulp therapy. Forty six (55%) teeth were included in the F group and 38 (45%) allocated to the C group. Five teeth were lost to follow-up, leaving 79 teeth: forty four (56%) in group F and 35 (44%) in group C. Eighty four percent (37/44) of teeth treated with formocresol and 77 percent (27/35) treated with calcium hydroxide were classed as clinically and radiographically successful at the cut-off date, December 1997, after a mean clinical review of 22.5 months (range 6.1-38.5 months) and a mean radiographic review of 18.9 months (range 1.3-36.9 months).

CONCLUSION

This investigation confirms the clinical efficacy of a one-fifth dilution of Buckley's Formocresol as an agent in pulp treatment of cariously exposed, vital primary molar teeth. However, calcium hydroxide in its pure, powder form is a clinically acceptable alternative when combined with strict selection criteria for this method of restorative care. There was a statistically insignificant difference in successful clinical and radiological outcome between the two treatment groups. Success was unrelated to the duration of time taken to achieve haemostasis and the presence or absence of bleeding after placement of the medicament.

Dissolution of root canal sealer cements in volatile solvents

AIM

There are few published data on the solubility profiles of endodontic sealers in solvents commonly employed in root canal retreatment. This study tested the hypothesis that root canal sealer cements are insoluble in the volatile solvents chloroform and halothane.

METHODOLOGY

Standardized samples (n = 5) of glass ionomer (Ketac Endo), zinc oxide-eugenol (Tubli-Seal EWT), calcium hydroxide (Apexit) and epoxy resin (AH Plus) based sealers were immersed in chloroform or halothane for 30 s, 1 min, 5 min and 10 min. Mean loss of weight was plotted against time of exposure, and differences in behaviour assessed by multiple paired t-tests (P < 0.01).

RESULTS

Clear differences were shown in the solubility profiles of major classes of root canal sealer cements in two common volatile solvents. In comparison with other classes of material, Ketac Endo was the least soluble in chloroform and halothane (P < 0.01), with less than 1% weight loss after 10 min exposure to either solvent. Apexit had low solubility with 11.6% and 14.19% weight loss after 10 min exposure to chloroform and halothane, respectively. The difference between solvents was not significant (P > 0.01). Tubli-Seal EWT was significantly less soluble in halothane than chloroform (5.19% and 62.5% weight loss after 10 min exposure, respectively (P < 0.01)). Its solubility in halothane was not significantly different from that of Apexit. AH Plus was significantly more soluble than all other materials in both chloroform and halothane (96% and 68% weight loss after 10 min exposure, respectively (P < 0.01)).

CONCLUSIONS

There are significant differences in the solubility profiles of major classes of root canal sealer in common organic solvents. Efforts should continue to find a more universally effective solvent for use in root canal treatment.

Development of a method to detect and quantify prostaglandin E2 in pulpal blood from cariously exposed, vital primary molar teeth

AIM

The aim of this in vitro study was to detect and quantify an established marker of inflammation, prostaglandin E2 (PGE2), in blood samples harvested from radicular pulp stumps after coronal pulp amputation.

METHODOLOGY

Harvesting was achieved by a paper strip 'dip-stick' method and the volume of each sample estimated before storage at -80 degrees C. A competitive, plate-based enzyme immunoassay technique (EIA) was developed for detection and quantification of the inflammatory mediator assumed to be present in blood samples. Since this technique had not previously been used to assess pulp blood, steps in the development of harvesting, storage, extraction and validation of this sensitive assay are described.

RESULTS

Thirty-nine single-blood samples were assayed and yielded detectable amounts of PGE2 ranging from 1.0 to 2641 ng mL-1.

CONCLUSIONS

The results of this investigation indicate that the inflammatory mediator, PGE2 can be detected and quantified in small blood samples from pulp stumps. Further development may derive quantitative tests for determining the condition of pulp tissue in primary molar pulp treatment.

Preclinical endodontology: an international comparison

AIM

The aim of this study was to compare preclinical endodontic teaching in Europe, Scandinavia and North America, and to place recent UK data in an international context.

METHODOLOGY

A postal questionnaire was sent to all undergraduate dental schools in North America, Scandinavia, and Europe. Data were requested on a range of issues relating to endodontic teaching.

RESULTS

Forty-three percent of the 170 schools surveyed returned completed questionnaires. There was considerable international consensus on the content of preclinical courses, with most schools advocating preflaring canal preparation techniques, sodium hypochlorite for irrigation, and cold lateral condensation as the standard obturation method. There was little consensus on the standard use of intracanal medicaments, though calcium hydroxide was universally popular. The practice of single visit treatment was advocated by at least 70% of schools in all geographical areas. A number of innovations appear to be gaining acceptance in preclinical teaching, with more than 20% of schools teaching the use of electronic apex locators, and a quarter of Western European, Scandinavian and North American schools embracing nickel-titanium instrumentation. Regional differences in the priority and resource given to endodontic teaching were striking. On average, UK schools had the worst staff:student ratios for preclinical endodontic teaching, and allocated substantially less time allocation for this teaching compared with Western European, Scandinavian and North American schools.

CONCLUSIONS

It was concluded that although teachers in the UK were broadly advocating techniques recommended elsewhere, the academic infrastructure and priority given for endodontic teaching in the UK was limited in the international context. This may have some impact on the quality of endodontic provision within the UK General Dental Services.

A comparison of graft implantation techniques for hair transplantation

Modern hair restoration surgery involves moving hair-bearing grafts from the posterior scalp into areas of hair loss for correction of androgenic alopecia. Over the past decade, this procedure has been refined in multiple ways for the creation of increasingly natural results. The following is a comparison of commonly used graft harvesting, sectioning, and implantation techniques currently in use for hair restoration today. This comparison includes data on total procedure time, graft cutting time, graft insertion time, labor requirements, and cost.

Cure behaviour of visible light-activated pattern materials

AIM

This study tested the hypothesis that the cure behaviour (depth of cure and polymerization contraction) of light-activated pattern materials was no worse than that of light-activated composite resins, allowing them to be handled in a similar fashion.

METHODOLOGY

Depth of cure was measured by a penetrometer method.

RESULTS

Cure depths were comparable to those of composite resins, ranging from 3.52 mm (Lumin-X paste) to 6.76 mm (Visioform) after visible light activation for 30 s. There were significant differences in the depth of cure of the three materials tested (P < 0.001). Polymerization contraction was assessed by a minimal load transducer method. Values ranged from 0.45% (Lumin-X paste) to 1.89% (Visioform), lower than that of composite resins. There were significant differences in the polymerization contraction values for each of the three materials (P < 0.001).

CONCLUSIONS

It was concluded that light-activated pattern materials cure in a manner comparable to composite resins, and may be built up incrementally in a similar fashion.

Methodology of follicular unit hair transplantation

This article discusses various techniques used in hair transplantation. Current techniques are compared in great detail. The cost-effectiveness of each technique and the various results one can achieve with each procedure is also discussed.

Vancomycin-induced linear IgA bullous dermatosis (LABD)

We report the eleventh case of vancomycin-induced linear IgA disease. Our case is unusual because symptoms developed within minutes of administration of the drug. We discuss the pathogenesis and review the literature.

Marginal leakage of Gallium Alloy root-end fillings: an in-vitro assessment

The sealing ability of amalgam and Gallium Alloy Gallium Filling (GF) root-end fillings was evaluated in vitro using a highly uniform collection of sheep incisor roots. Following ultrasonic canal debridement and orthograde obturation with gutta-percha and sealer, root-end cavities were prepared in 100 roots and filled with amalgam (50 teeth) or Gallium Alloy GF (50 teeth), Twenty-five teeth from each group were subjected to immediate dye leakage assessment under vacuum conditions with methylene blue dye (2%), pH 7. Linear dye penetration was measured following longitudinal splitting. The other 25 teeth from each group were incubated in Ringer's solution for 12 weeks before leakage assessment by the same method. Control teeth were included in each component of the study. Mean linear dye penetration was: amalgam--5.17 mm at baseline, 2.33 mm after 12 week's incubation; Gallium Alloy GF--2.21 mm at baseline, 1.41 mm after 12 week's incubation. The apical marginal seal of both materials improved significantly following storage in Ringer's solution (P<0.001). Gallium Alloy GF provided a better apical seal than amalgam, both at baseline and following storage (P<0.001). Subjective evaluation of the general handling characteristics of Gallium Alloy GF revealed that it was a more difficult material to manipulate than amalgam, largely because of its wetting ability and consequent adhesion to dental instruments.

The physical properties of a gallium alloy restorative material

OBJECTIVES

This study was conducted to compare the physical properties of a gallium alloy restorative material and a widely used mercury-containing dental amalgam.

METHODS

Although the specimens were not prepared according to ISO specifications, specimens of both materials were subjected to ISO standard (ISO 1559; 1986) tests. The results were analyzed by ANOVA, Mann-Whitney U test and Student's t-test.

RESULTS

The gallium alloy showed setting expansion which was greater than that for the other amalgam and greater than the upper limit set by the ISO standard. For other properties, gallium alloy performed as well as, and in the case of creep, was superior to that of the amalgam.

SIGNIFICANCE

The gallium alloy proved difficult to manipulate even when using the PTFE coated instruments recommended by the manufacturer. It is suggested that while the material may prove to be a viable alternative to conventional dental amalgam, a considerable improvement in its handling characteristics would be required before it would gain widespread acceptance for clinical use.

Use of rapid carbohydrate utilisation test for identifying "Streptococcus milleri group"

A short series of biochemical and serological tests were developed for the rapid presumptive identification of "Streptococcus milleri group" isolates. One hundred and seventy seven streptococcal isolates were recovered from the mouths of 10 out of 12 healthy adult volunteers by use of a simple sampling procedure and a single selective medium. In all, 127 oral "S milleri group" isolates were identified by biochemical and serological tests, confirming the indigenous nature of these streptococci in the mouth. Most (70.1%) of "S milleri group" isolates were non-haemolytic, 26% were alpha-haemolytic, and 3.9% beta-haemolytic. Fifty four (42.5%) were serologically typable, of which 46 were Lancefield group F, suggesting that the mouth is an important source of Lancefield group F streptococci. A collection of group F streptococci from a range of sources was indistinguishable from a collection of oral "S milleri group" isolates on the basis of the tests used, supporting the general synonymity of group F streptococcus with the broader "S milleri group". The battery of tests was cheap and simple to perform, and was capable of identifying "S milleri group" isolates from a range of sources, including variants with wide sugar fermentation patterns.

Medical foster family care: a cost-effective solution to a community problem

In response to the special needs of a small number of abused and neglected children who were being cared for by unnecessary extended hospitalization, a medical foster family care program was established, at much lower cost, to provide the children with a home environment and assist their parents so that family reunification was possible.