Opinions of UK General Dental Practitioners on the Restoration of Posterior Root Filled Teeth: a Vignette Survey.

OBJECTIVE: To investigate factors which influence UK general dental practitioners (GDPs) when restoring posterior root filled teeth. METHOD: An electronic survey was designed to explore current strategies of treatment of posterior root filled teeth by UK-based GDPs working in primary care. Three vignette cases included in the questionnaire explored a variety of tooth, patient, and financial factors. The survey was distributed by email and social media platforms between December 2018 and February 2019. RESULTS: A total of 528 valid responses were collected. The majority of participants (84.1%) regularly restored posterior root filled teeth with an indirect restoration. Presence of persistent symptoms post root canal treatment (RCT) completion would impact the management of 85% of the surveyed respondents. Referral to a specialist, deferral of provision of the definitive restoration, and fear of litigation were reported by the GDPs as influencing factors. CONCLUSION: This survey highlights that decision making regarding restoration of root filled teeth is a multifactorial process. Tooth, patient, and financial factors were all shown to influence the restorative management of the posterior root filled teeth.

EUROPEAN SOCIETY OF ENDODONTOLOGY Undergraduate Curriculum Guidelines for Endodontology.

Undergraduate education should accomplish graduates who are skilled to provide quality care for patients, who are aware of their scope of practice, competency level and limits and who are open to referring patients whose needs are beyond their own skills and experience. They should also become self-efficacious. Quality performance begins with good diagnosis and decision-making. Graduates should understand when to treat, why to treat, what to treat and how to treat. These guidelines include a list of capabilities that the graduating student will be expected to have achieved to provide a minimum level of competency in endodontics. Theoretical knowledge, practical skills, understanding and insight should be assessed, with both formative and summative assessment procedures, making use of reflection and feedback. Endodontic procedures should be undertaken within the context of comprehensive patient care and should be evidence based. Students should not perform treatments on patients until they have demonstrated in a pre-clinical setting that they possess the required skills. Only if it is not possible to simulate a specific procedure sufficiently in a pre-clinical setting should students learn this procedure by performing it clinically under close supervision. Clinical endodontics should ideally be supervised by endodontists or by staff with special knowledge, interest and self-efficacy in endodontics. It is advised to ensure that students apply their knowledge and practice their skills periodically throughout the continuum of endodontic education until graduation. A philosophy of lifelong learning and evidence-based practice should be instilled in all dental undergraduates.

Is External Cervical Resorption an Established Manifestation of Systemic Sclerosis? A Case Report.

Scleroderma, or systemic sclerosis, is a multisystem autoimmune disorder characterized by hardening and fibrosis of the skin. To date, only a small number of case reports have established a relationship between scleroderma and external cervical resorption (ECR). The aim of this case report is to document the case of a patient with multiple external cervical resorption lesions, who was referred to our unit. A 54-year-old female patient, with a 10-year history of systemic sclerosis diagnosed by her rheumatologist, was referred to our unit regarding extensive ECR. A total of 14 maxillary and mandibular teeth with ECR were detected by clinical examination and cone-beam computed tomography. The characteristic vascularity of resorptive defects with profuse bleeding upon probing was not evident. The patient declined any active treatment owing to the desire to avoid lengthy and unpredictable treatment, which may hasten the loss of her teeth. General practitioners should be aware of the relationship between connective tissue disorders and ECR. Although not well established in the literature, the vascular changes implicated in scleroderma may stimulate the odontoclastic processes involved in ECR.

Which endodontic access cavity is best? A literature review.

The preparation of an access cavity is the first part of endodontic treatment and is a key stage in the healing of both periapical and pulpal infections. It should allow endodontists to remove obstructions in the pulp chamber, locate all canal orifices and clean the entire root canal system with minimum coronal tooth structure removed. This has been done traditionally through establishing straight line access. The development of minimally invasive endodontics aimed to preserve as much of the natural tooth structure as possible, particularly dentine, while undertaking root canal treatment, resulting in the development of other access cavity preparations. This includes conservative, ultra conservative (ninja), truss, guided access, caries-orientated and restorative access cavities. These access cavity preparations also gained popularity due to increased magnification and enhanced lighting, allowing practitioners to visualise the pulpal space in greater detail throughout treatment.Our current recommendation is to conduct access cavities traditionally rather than conservatively. Ideally, conservative access cavities need magnification, which might not be available for all clinicians. With traditional access cavity, the procedure takes less time and it is more predictable to locate the canal orifices, deliver irrigation effectively, avoid iatrogenic damage with biomechanical preparation and achieve better obturation.

Management of traumatic dental injuries: a survey of paediatric emergency department health professionals.

OBJECTIVE: To assess paediatric emergency department (PED) health professionals' confidence, experience and awareness in managing traumatic dental injuries (TDIs). DESIGN: A cross-sectional online survey. SETTING: PED at Alder Hey Children's Hospital and Birmingham Children's Hospital. RESULTS: 94 ED health professionals responded. One-third of responders (n=26) encounter children with dental trauma daily or weekly. TDI teaching during undergraduate training was received by 13% (n=12) of responders, and 32% (n=30) had never received training. Responders thought they would benefit from online resources and regular teaching on paediatric TDIs, in addition to an easy-to-use decision-making tool to signpost families.ED health professionals' confidence in giving advice to families following a TDI, and in recognising types of TDIs, was notably low; -79 and -76 Net Promotor Score, respectively.Responders' awareness of how to recognise and manage TDIs was varied. Majority were aware of the need to attempt to reimplant an avulsed permanent tooth, and the need to refer a child presenting with a complex permanent tooth injury to the oncall dentist. However, very few responders commented on the importance of follow-up. Responders also raised concerns about the lack of dental services to treat TDIs in children. CONCLUSIONS: There is a need to enhance dental trauma teaching for all ED health professionals who encounter TDIs to increase their confidence and enable them to triage and advise patients appropriately. Additionally, increased signposting for families to the appropriate service could in turn improve outcomes and experience for children who experience a TDI.

Suspected Endodontic Failure in a Patient with Cleidocranial Dysplasia: A Case Report.

A patient's medical history and related dental manifestations can significantly contribute to confounding signs and symptoms leading to a diagnostic challenge. An 18-year-old female patient presented with persistent radiographic radiolucency associated with the apex of a previously treated tooth (tooth 9); asymptomatic apical periodontitis and endodontic failure were suspected. This report presents how a patient's condition of cleidocranial dysplasia had a profound effect on her dental history, which included the presence of multiple supernumerary teeth. Extensive surgical intervention during the patient's childhood was required to remove the supernumerary teeth, which resulted in an endodontic misdiagnosis in her adult life. After clinical and radiographic examination, the patient was diagnosed with a periapical scar. Periapical fibrous scars have a prevalence of between 2.5% and 12% and are a rare healing process with fibrous tissue after surgical and nonsurgical interventions. This report describes the diagnosis and pathophysiology of fibrous scars, including their risk factors and long-term monitoring approaches.

The epidemiology of endodontic complexity in general dental practice: a prevalence study.

Aim To determine the prevalence and the epidemiology of the factors influencing endodontic complexities in general dental practice.Method Eligible cases where endodontic treatment was indicated as a treatment option were collected by a total of 30 general dental practitioners based in the UK. Online-based Endodontic Complexity Assessment Tool (E-CAT) was used to determine the perceived complexity of each case. In total, 22 categories, including patient- and tooth-related factors, were recorded.Results Collectively, 435 non-surgical root canal treatment cases were assessed. Overall, 72% of the root canal treatments encountered in general dental practice were found to be either uncomplicated (Class I) or moderately complicated (Class II) and can be considered within the remit of general dental practitioners. Despite the relatively equal distribution of the assessed teeth, the proportion of extraction as a proposed treatment for posterior teeth was more than double that of anterior teeth.Conclusion The results obtained in this study provide a good resource and databank for researchers, educators, public health commissioners and academic institutions to access a wide range of information concerning the prevalence and distribution of endodontic complexity.

Molar-incisor hypomineralisation combat: exploratory qualitative interviews with general dental practitioners in England regarding the management of children with molar-incisor hypomineralisation.

Introduction Molar-incisor hypomineralisation (MIH) presents as a spectrum, with severe cases becoming increasingly complex to manage. This study aimed to investigate the perceptions and experience of general dental practitioners (GDPs) in England when managing children with MIH.Method Semi-structured telephone interviews with GDPs who regularly treat children took place in May 2020. A sample of four male and six female GDPs with 1-15 years of experience was achieved through purposively sampling interested parties following advertisement via professional groups. Thematic analysis using a realist and inductive approach was used in analysis.Results The overarching theme was of managing uncertainty, with four subthemes: setting the scene; fighting the tooth; working within the system; and self and interpersonal insight. Despite being knowledgeable, participants expressed varying levels of confidence in many aspects while managing children with MIH. There was a great deal of uncertainty surrounding 'doing the right thing' across the themes. Systemic barriers to managing children with MIH within the general dental service were identified.Conclusion The challenges of managing children with MIH was experienced as 'uncertainty'. Barriers within the general dental service made managing children with MIH difficult and participants relied on colleagues in secondary care to manage severe cases.

Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP): a feasibility study.

BACKGROUND: Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology's (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice. METHOD: This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis. DISCUSSION: The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN17973604 . Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021.

The transitional care pathway following traumatic dental injuries: Patient perspectives.

BACKGROUND AND AIM: The nature of complex traumatic dental injuries (TDIs) often means that management continues through paediatric to adult dental services. Evidence suggests that failure in transitional care can have detrimental impacts on health. There is limited evidence regarding patients' experiences of transitional care pathways (TCPs) in dentistry. The aim of this study was to investigate the views and experiences of the TCP from paediatric to adult care for individuals who have experienced TDIs. MATERIALS AND METHODS: Semi-structured interviews were undertaken. Ethical approval was granted by the Health Research Authority and sponsored by the University of Liverpool. Inclusion criteria included individuals aged 16 to 21 years old who had received care in both paediatric and adult restorative dentistry departments at Liverpool University Dental Hospital following a TDI. Five purposively sampled patients were interviewed. Thematic analysis was undertaken using NVivo. RESULTS: Thematic analysis identified 5 main themes with regard to transitional care experience: patient-clinician communication, impact of dental trauma, feelings of uncertainty, patient personal development and transitional care planning. Feelings of uncertainty with regard to the long-term prognosis of traumatized teeth were highlighted. Clear communication and involvement of young people in decision-making was identified as a vital factor to facilitate a successful TCP experience. CONCLUSION: The involvement of young people in decision-making is essential for a successful TCP. Consideration should be given to development of TCP guidance, to allow for the provision of timely and consistent information regarding the process. Despite this, there needs to be adaptivity within the TCP to create a successful TCP for every young person.

Electrical stimulation to clinically identify position of the lingual nerve: results of 50 subjects with reliability and correlation with MRI.

PURPOSE: Recently we described mapping of the lingual nerve clinically in patients using electrical nerve stimulation. This paper reports results of a larger study with inter- and intra-observer reliability and comparison with positional measurements from magnetic resonance imaging (MRI). METHODS: In 50 healthy participants, measurements were taken when subjects felt a tingling sensation in the tongue induced by a stimulation probe over the lingual nerve. Three positions were measured in relation to the third molar. Measurement reliability was tested for both inter-observer and intra-observer agreement and positional data of the lingual nerve measured clinically was also compared with nerve position as measured from MRI scans. RESULTS: Out of 50 participants, 96 nerves (49 = left/47 = right) were included in the study. The lingual nerve was identified in 90% (87) of this sample. The mean of height of the nerve in points A, B and C were 9.64 mm, 10.77 mm and 12.34 respectively. Inter-and intra-observer agreement was considered to be good to excellent (ICC = 0.8-0.96). Agreement between nerve mapping measured values and MRI measured values was good (ICC < 0.6). CONCLUSION: This technique may prove useful for the clinical determination of lingual nerve position prior to procedures in the third molar region.

An investigation of transitional care pathways for young people following traumatic dental injuries.

Introduction Traumatic dental injuries (TDIs) can cause severe and complex dento-alveolar problems. Management of TDIs frequently extends into adulthood; therefore, a clear transitional care pathway (TCP) is important. Failure of this can prevent engagement in adult dental services and negatively influence treatment outcomes.Aims To assess the availability of TCPs from paediatric and adult specialist care for young people with TDIs.Materials and methods An anonymous, postal survey was designed and administered to all UK specialists in paediatric dentistry registered with the General Dental Council. Quantitative and qualitative data were gathered.Results The response rate was 58% (n = 130). Fifty-five percent (n = 72) stated that there was a dental trauma clinic for children within their locality, while only 22% (n = 29) stated that there was a dental trauma clinic for adults. Sixty-nine percent (n = 90) stated that there was no clear TCP within their locality and 41% (n = 37) of these highlighted a need for a TCP. Thematic analysis of opinions with regards to need for a TCP identified three main themes: pathway availability, access to resources and clinician experience. Following a course of treatment for a patient aged 12 years or above, 24% (n = 31) refer to specialist adult services, with 43% (n = 95) continuing to provide follow-up within paediatric dentistry.Conclusion Follow-up arrangements for young people with TDIs differ across the UK, with inconsistent availability of TCPs. Informal pathways involving referral to multidisciplinary teams may be utilised for follow-up care. Development of a TCP may aid in developing a consistent approach to long-term management of TDIs.

Management of molar-incisor hypomineralisation by general dental practitioners - part two: treatment.

Introduction Molar-incisor hypomineralisation (MIH) is a common occurrence in primary and secondary care settings. While severe cases may need specialist care, mild cases should be managed in primary care.Aims To assess how UK-based general dental practitioners (GDPs) plan treatment for children with MIH using two clinical vignettesDesign An electronic vignette survey was designed using clinical photographs and radiographs. Vignette one presented a child with mild MIH who was unhappy about the appearance of his teeth. Vignette two presented an anxious child with severe MIH, caries and sensitivity. Further questions relating to confidence in management of MIH and referral were included. Participants were UK-based GDPs who regularly treat children. The survey was distributed by email and across social media platforms. Data collection occurred between February and May 2019.Results Fifty-eight GDPs completed the survey. Around half of participants addressed the aesthetic concerns of the child in vignette one. The majority of participants demonstrated sound treatment planning in terms of preventive care and management of molars. More GDPs identified increased caries risk in vignette two.Conclusion These findings demonstrate most GDPs in this study were working as effective tier one and two providers when faced with management of children with MIH.

Management of molar-incisor hypomineralisation by general dental practitioners - part one: diagnosis.

Introduction Molar-incisor hypomineralisation (MIH) affects one in six children in the UK. For the majority of patients who have mild MIH, this should be managed in primary care.Aims To assess UK-based general dental practitioners' (GDPs) ability to diagnose MIH when presented with multiple clinical vignettes.Design An electronic vignette survey was designed with use of clinical photographs - six cases had MIH and/or hypomineralised second primary molars (HSPMs) (seven possible diagnoses). Four control cases showing caries, fluorosis, amelogenesis imperfecta and dentinogenesis imperfecta were also included. Participants were UK-based GDPs. The survey was distributed by email and across social media platforms. Data collection occurred between February and May 2019.Results Seventy-six GDPs completed the survey; 68.4% (n = 52) of participants were female and 83% (n = 63) of participants graduated after the year 2000. The number of accurate diagnoses for each case were as follows - mild MIH (molars/incisors) 65.79%; mild MIH (molars only) 3.95%; HSPM and MIH (HSPM result) 0%; HSPM and MIH (MIH result) 50%; severe MIH (post-eruptive breakdown) 63.16%; severe MIH (caries) 31.58%; HSPM 3.95%.Conclusion GDPs are able to accurately diagnose MIH best when both incisors and molars are affected and caries is not present.

SARS-CoV-2: characterisation and mitigation of risks associated with aerosol generating procedures in dental practices.

Introduction The objectives were to characterise the particle size distribution of aerosols generated by standard dental aerosol generating procedures (AGPs) and to assess the impact of aerosol-management interventions on 'fallow time'. Interventions included combinations of high-volume intraoral suction (HVS[IO]), high-volume extraoral suction (HVS[EO]) and an air cleaning system (ACS).Method A sequence of six AGPs were performed on a phantom head. Real-time aerosol measurements (particle size range 0.0062-9.6 µm) were acquired from six locations within a typical dental treatment room (35 m3).Results The majority (>99%) of AGP particles were <0.3 µm diameter and remained at elevated levels around the dental team during the AGPs. With no active aerosol-management interventions, AGP particles were estimated to remain above the baseline range for up to 30 minutes from the end of the sequence of procedures.Conclusions The results emphasise the importance of personal protection equipment, particularly respiratory protection. Use of HVS(IO), either alone or in combination with the ACS, reduced particle concentrations to baseline levels on completion of AGPs. These data indicate potential to eliminate fallow time. The study was performed using a phantom head so confirmatory studies with patients are required.

Methodological Quality of Systematic Reviews Relating to Performance of All-Ceramic Implant Abutments, Frameworks, and Restorations.

PURPOSE: To assess the methodological quality of published systematic reviews relating to all ceramic implant frameworks, abutments and restorations. MATERIALS AND METHODS: Published systematic reviews relating to all ceramic implant restorations for single tooth and multiple teeth replacements were retrieved to assess their methodological qualities. Sixteen systematic reviews were included for methodological quality assessment by two independent assessors using AMSTAR-2 critical appraisal tool. Inter-rater agreement was assessed using the weighted Cohen's Kappa statistic. RESULTS: Most systematic reviews included randomized clinical trials and nonrandomized studies of intervention. The majority of included systematic reviews (15 out of 16) scored critically low on quality with more than one critical flaw when assessed using the AMSTAR-2 tool. Most systematic reviews assessed lacked analysis of the effects of the risk of bias and heterogeneity of the included studies. The inter-rater agreement of the independent assessors was substantial (0.63). CONCLUSIONS: Confidence in the evidence presented in these systematic reviews was undermined by their tendency to overlook the effect of risk of bias and heterogeneity in evidence synthesis.

The Surgical Management of External Cervical Resorption: A Retrospective Observational Study of Treatment Outcomes and Classifications.

INTRODUCTION: The aims of this study were to assess the survival and clinical success of patients with teeth with external cervical resorption (ECR) who underwent surgical repair, to assess the reliability of using 2 different classification systems for ECR (Heithersay 2-dimensional classification and Patel 3-dimensional classification), and to identify if a 3-dimensional classification is a viable alternative. METHODS: A retrospective study was performed in a teaching dental hospital in England. The inclusion criteria were limited to patients who underwent surgical management of ECR between 2015 and 2018. Both periapical radiographs and cone-beam computed tomographic scans of 13 patients were assessed by 2 independent dental practitioners using the Heithersay and Patel classifications. The same radiographic assessment of those records was then repeated 3 weeks later by 1 operator. These data were tested using the Cohen kappa analysis to determine inter- and intraobserver agreement. RESULTS: A total of 14 teeth affected with ECR were identified in 13 patients (6 women and 7 men) with a mean age of 41 years. The mean follow-up was 20 months. At follow-up, survival was noted in all cases; however, clinical success describing endodontic success, comprehensive restorative integrity, and arrest of the resorptive process was only met in 11 cases. Although helpful in describing the lesions, both classification systems displayed considerable limitations in predicting treatment outcome. A measure of Cohen kappa regarding interobserver reliability found the Heithersay classification to provide a moderate level of agreement (0.69), whereas the Patel classification provided a weak level of agreement (0.40). CONCLUSIONS: ECR is a complex, aggressive, and uncommon form of external resorption. The long-term success of the treatment is predictable but strictly related to careful case selection and operative skill. In reference to ECR classifications, ambiguity still exists between their distinctive categories, leading to moderate and weak levels of interobserver agreement. Further improvement is required to enhance their use in future research.

The use of mineral trioxide aggregate to achieve root end closure: three case reports.

The use of mineral trioxide aggregate (MTA) to achieve root end closure has many advantages over the traditional calcium hydroxide (Ca(OH)2) technique including the reduced number of visits and the reduced mechanical damage to dentine. Limited studies have reported the outcome of using MTA as an apexification material and a one-stage obturation technique in non-vital immature teeth. This article illustrates three successful clinical cases where MTA was used as an apexification material. In case study one: Type 1 Dens Invaginatus tooth with incomplete root formation, case study two: an immature tooth that suffered pulp necrosis following an enamel and dentine fracture trauma and case study three: a non-vital tooth following an apical root fracture.

Assessment of perceptibility and acceptability of color difference of denture teeth.

OBJECTIVES: To assess the color difference values that represent the perceptibility and acceptability thresholds of denture teeth. METHODS: Eighteen interchangeable right upper central incisors denture teeth were selected to have color difference values from representative left upper central incisor denture tooth in a range of 0.4-11.4 ΔE* units measured with a spectrophotometer (CM 2600d, Minolta Konica, Japan). These teeth were placed in an artificial dental arch in a phantom head. Under controlled conditions, a total of 80 observers divided into 4 groups (technicians, nurses, dentists and researchers) were asked to report the perceptibility and acceptability of each of the color difference values. The findings was then analysed using logistic regression for determining the perceptible and acceptable thresholds of dental color differences. RESULTS: The determined color difference values at which 50% of all observers could detect a color difference (50:50 probability) was 1.9 ΔE* units with a 95% confidence interval and ranged from 1.7 ΔE* units to 2.1 ΔE* units. The determined color difference value at which 50% of all observes preferred to replace the tooth because of unacceptable color difference (50:50 probability) was 4.2 with a 95% confidence interval that ranged from 3.9 ΔE* units to 4.7 ΔE* units. CONCLUSIONS: Within the limitation of this study, the following conclusions were made: 1. The mean color perceptibility threshold was significantly lower than the mean color acceptability threshold. 2. Significant differences between different observers groups were noticed in determination of perceptibility and acceptability of color differences. The technicians groups displayed lower perceptibility and acceptability limits than the dental nurses and non-dental observers. CLINICAL SIGNIFICANCE: When shade matching artificial denture teeth to natural teeth, 50:50 perceptibility (1.9 ΔE* units) and acceptability (4.2 ΔE* units) thresholds are used to compare color difference values. The technicians group displayed lower perceptibility and acceptability limits than other observers.