Thursday, February 26, 2015

Considerations for Regeneration Rrocedures

Article Title: Considerations for Regeneration Rrocedures
Author: Alan S. Law, DDS, PhD
Journal/Date: Pediatric Dentistry, Vol. 35 No. 2 March/April 2013
Resident: Slowikowski

Major Topic:  Review the literature related to regenerative endodontic procedures.

Main Purpose:  Discuss consideration for Regenerative endodontic procedures and they can increase the prognosis for immature teeth with necrotic pulp tissue. 

Introduction:  Dental trauma in an immature tooth can lead to many problems.  Pulp necrosis and incomplete root formation make endodontic therapy difficult, which can lead to premature loss of permanent teeth and a compromised dentition.  Blunderbuss apices make immature teeth harder to clean, shape, and obturate; not to mention thin root walls are easy to fracture.  The concept of revitalizing root canal tissue has been around since the 1970’s.  Two recent studies have created interest in this concept.  Both case reports showed 3 important principles of regenerative endodontics:
1.    Elimination of bacteria from the canal system
2.   Creation of scaffold for the ingrowth of new tissue
3.   Prevention of reinfection by creating a bacteria-tight seal

There are 3 terms that are used to describe new living tissue into the canal space. 
·      Revascularization – re-establishment of the vascular supply to existing pulp in immature permanent teeth.
·      Revitalization - ingrowth of tissue that may not resemble of the original lost tissue
·      Regeneration – replacement of damages structures, including dentin and root structures, as well as the pulp-dentin complex

Studies that have been able to look at the histology of the regenerative tissue have found loose connective tissue that is similar to that of pulpal tissue.  Although this may not be representative of all teeth.

In the 2000 there have been several case studies that address regeneration of the pulpal tissue in a necrotic, immature permanent tooth.  

1.    Younger patients (6-18 y/o)
2.   Permanent teeth with immature apices.
3.   Minimal to no canal instrumentation
4.   Placement of an intercnal medicament
5.    Placement of a bacteria-tight seal at the completion of the tretment

1.    Type and concentration of irrigants (1.25-5.25% NaOCl with and without the use of Peridex or 3% hydrogen peroxide
2.   Type and concentration of the intercanal medicaments (TAP, double antibiotic paste, calcium hydroxide)
3.   Number of appointment and the length of time in between appointments (none to 3 months)
4.   Creation of a blood clot verses the use of another scaffolding type (PRP – platelet-rich plasma; AFM – autologous fibrin matrix)
5.    Type of pulp space barrier
6.   Final restoration

American Association of Endondontists (AAE) Regenerative Endodontics Committee created a document that gave the most current recommendations and are summarized here.

A few clarifying details:
Case selection:
·      Necrotic pulp -etiology does not matter (trauma, dental anomalies, decay)
·      Pulp space barrier is needed so no post space
·      Stem cells – aka immature apices have increase source compared to mature apices
Informed consent:
·      Antibiotics – must question parents for allergies
·      Make sure to mention alternative treatments if regenerative therapy fails
First Appointment:
·      Chlorhexidine is also cytotoxic to stem cells
·      Diluted concentrations of antibiotics because of detrimental effects on stem cells
·      TAP can cause discoloring: eliminate minocycline, seal coronal dentin with dentin bonding agent, composte or calcium hydroxide paste
Second appointment:
·      LA with out vasoconstrictor is recommended so that bleeding can be induced with extraneous influences
·      Draw backs to use of PRP and AFM for a scaffolding, is an additional blood draw

Described out comes of REP in the literature:
Andreasen and Bakland – 1200 traumatized teeth; 320 autotransplanted premolars:
1.    Revascularization of the pulp with accelerated dentin formation leading to pulp canal obliteration
2.   Ingrowth  of cementum and periodontal ligament
3.   Ingrowth of cementum, PDL, bone
4.   Ingrowth of bond and bone marrow
Chen et al.  – 20 teeth
1.    Increased thickening of the canal walls and continued root maturation
2.   No significant continuation of root development with the root apex becoming blunt and closed
3.   Continued root development with the apical foramen remaining open
4.   Severe calcification (obliteration) of the canal space
5.    A hard-tissue barrier formed in the canal between the coronal MTA plug and the root apex

Discussion: good overview of REP, must keep up-to-date, quickly evolving field

Contemporary Management of Horizontal Root Fractures to Permanent Dentition Diagnosis – Radiologic Assessment to Include Cone-Beam Computed Tomography


Article title: Contemporary Management of Horizontal Root Fractures to Permanent  Dentition Diagnosis – Radiologic Assessment to Include Cone-Beam Computed Tomography

Authors: May et. al

Journal: Pediatric Dentistry V35/No.2 Mar/Apr 13

Abstract: Historically, several PAs have been recommended to diagnose horizontal root fractures. Assessing orientation is correlated to treatment and outcome.  Conventional radiography yields only limited information fro diagnosis. Cone-beam computed tomography (CBCT) is a supplement conventional radiography for evaluating horizontal root fractures. The purpose of the article is meant to be a preliminary guideline for cases of suspected horizontal root fracture as a result of trauma. 

·      Horizontal root fracture (HRF) incidence is low and is reported to range from 0.5%-0.7% when compared with other dental impact injuries.
·      HRFs are found in maxillary central incisors (68%) and maxillary lateral incisors (27%) and only 5% in mandibular incisors.
·      CBCT scans may be considered for accurately diagnosing HRFs, but higher levels of radiation, higher costs and sufficient training for evaluation of data have raised concerns.
·      PUBMED search of horizontal root fractures and CBCT.
·      Case studies and systematic reviews were included as well as 1 animal study.
Outcome of HRF
·      20% of teeth with root fractures did not heal but pulpal necrosis occurred.
·      60% of teeth with root fractures exhibited external root resorption.
·      Time elapsed between trauma and treatment, stage of root development and signs and symptoms of mobility and pain may influence the type of healing.
·      Communication of the fracture line with the oral cavity resulted in pulpal necrosis. Healing usually occurs when fracture is not in the cervical third.            
·      Fractures in the middle third of root are most common.
·      Fracutres confined to apical, middle third with lesser separation, younder age of patient and lack of mobility subsequent to injury tend to lead to a better prognosis.

Clinical and Radiographic Examination of HRF
·      Clinical evaluation includes:
o   Assessment of mobility, presence or absence of tenderness and pain to palpation of te soft tissues, percussion of affected teeth and pulp vitality and sensitivity tests.
·      Common clinical signs of HRF:
o   Bleeding into sulcus, mobility of coronal fragment and history of impact trauma to the alveolus or teeth.
·      Recommendation by several organization of radiographic diagnosis of traumatic dental injuries.
o   Multiple Pas recommended and more recently consideration of CBCT because accurate visualization of root fracture allows the clinician to better choose a course of treatment.
·      Conventional radiographs:
o   Limitation for diagnosing a HRF due to projection geometry, superimposition and processing errors.
o   Often the fracture line does not show if the x-ray beam does not pass directly through the fracture line.
o   Minimal fracture displacement, structure superimposition, soft tissue swelling and foreign objects can complicate appearance of a fracture.
·      Because of the risk of misdiagnosis of location and course of fracture intraoral radiography could lead to improper treatment planning and unfavorable outcomes.
o   CBCT was therefore suggested as the imaging modality of choice for diagnosing HRFs.
·      Ranking of imaging modalities based on sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 1) CBCT, 2) Multidetector helical CT (MDHCT) followed by conventional radiography.

Concluding Remarks and Recommendations:
·      Before using CBCT it should be considered that children are at greater risk than adult from a given dose of radiation.

·      Clinical outcomes depend on location of fracture. CBCT is useful in revealing the fracture in the sagittal plane.

Pulp and Periradicular Testing

Article: Pulp and Periradicular Testing
Author: Linda Gibson Levin, DDS
Journal: Pediatric Dentistry Vol 35. March/April
Resident: Maclin

Pulp and periradicular testing is crucial to the initial trauma evaluation and to subsequent monitoring of the traumatized teeth and supporting structures. An accurate diagnosis serves as the basis for therapeutic intervention. With an end goal to minimize destruction of the dental structures and regain function.

To present the current best evidence for accurate diagnostic testing of the pulp and periapex of traumatized teeth. 

Five databases were searched for literature pertaining to pulpal testing and trauma. Widely recognized textbooks were also consulted. Currently used pulp vitality testing is constrained by its subjective character and by the fact that it is a measure of neuronal status and not true pulpal viability. Tests that measure tissue perfusion more accurately reflect pulpal vitality, but they are not available commercially. This review discusses the specificity, sensitivity, and accuracy of commonly used tests, with emphasis on the applicability of certain tests to specific patient presentations in trauma. Factors that influence test selection are discussed, and specific recommendations are made on the basis of best evidence. 

Periradicular Testing Methods:
Percussion Sensitivity
Palpation Sensitivity

Pulpal Testing Methods: 
Electric Pulp Test
Thermal Sensitivity Test

Experiments Test Methods:
Laser Doppler Flowmetery
Pulse Oximetry
Dual-Wavelength Spectrophotometry


A variety of periradicular and pulp vitality tests exist to evaluate and monitor the trauma patient. Present pulp vitality tests all depend on the presence of intact nerve endings. This selection and interpretation is highly dependent on several predictive factors or prior/pretest probability such as the age of the patient, the time since the initial trauma, the type of trauma sustained, the degree of root-end development, and the presence of pulp canal mineralization. These tests when combined with radiographic and clinical findings, they provide a basis for therapies designed to preserve the dentition.  Newer methods of testing pulpal vitality promise to increase our diagnostic accuracy in the trauma patient to even higher levels. 

Epidemiology of Traumatic Dental Injuries

Anna Abrahamian
February 25, 2015

Article Title:  Epidemiology of Traumatic Dental Injuries

Author: Lars Andersson, DDS, PhD, DrOdont

Journal:  Pediatric Dentistry, Volume 35(2): 102-105

Date: March/April 2013

Major Topics: Dental Trauma

Background: The oral region comprises 1% of the total body area, yet it accounts for 5% of all bodily injuries. Oral injuries are most frequent during the first 10 years of life and become more rare after age 30.  Of all the patients seeking consultation or treatment for injuries to the oral region, dental injuries are the most common and are seen in as many as 92% of patients presenting with oral injuries.
Incidence: The incidence of dental injury in children in most studies is between 1-3%.
Prevalence: Primary dentition – 30%; Permanent dentition – 20%; a large survey in the US (1988-1991) showed that 1 in 4 adults had evidence of incisal trauma.
Economic Impact: In a Swedish study, the direct and indirect costs of dental trauma were estimated to be $3.3-$4.4 million per 1 millions individuals in patients up to age 19.
Etiologic Factors:  Preschool children – falls; School-age children – sports or hits by another person; Adolescents/young adults – assaults and traffic accidents
Prevention: Sports injuries appear to offer some opportunities for prevention by the use of properly fitted custom mouth guard.
Increasing Lay Knowledge: It is critical that not just the professionals have first aid knowledge regarding dental trauma.

Organization of Emergency Care:  The author suggests that a dental emergency service organized in each geographic region be implemented. This service would be provided on a 24-hour basis ideally, but likely manage only emergencies that occur outside of regular dental office hours.

Wednesday, February 25, 2015

Dental Trauma Guidelines

Authors: Bakland, DDS
Journal: Pediatric Dentistry Vol 35 Mar/April 2013

  • earliest trauma guidelines go back to 1982
  • purpose of the guidelines is to give health care providers convenient access to current recommendations for treatment that is evidence based
  • its been shown that following published guidelines for dental trauma management has resulted in better outcomes than when the guidelines are not followed, one should probably not assume that guidelines are established standards of care
    • the judgement of the clinician in each individual clinical situation is an essential component of treatment recommendations
  • www.iadt-traumaguide.or or in print