Root canal treatment of compromised teeth as alternative treatment for patients receiving bisphosphonates: 60-month results of a prospective clinical study.

AIM: This 60-month prospective study aimed to evaluate tooth survival and healing rates after root canal treatment in patients taking bisphosphonates (BPs). Secondary outcomes were complications and clinical variables observed during and after treatment. METHODS: Root canal treatment was performed using manual K-file canal instrumentation and a carrier-based filling technique with an epoxy resin-based sealer. Teeth without adequate root/crown integrity were restored by trained operators at the tissue level (TL group) to prevent occlusal/mechanical stress and to enable periapical lesion healing without the risk of root fracture. Other teeth were restored with normal occlusal contacts (OC group). Healthy patients who had undergone one or more root canal treatments of the same type constituted the control group. The relationships of the following variables to survival and health status were examined (chi-squared test and multivariate analysis, P = 0.05): age, gender, smoking habit, tooth location, treatment type, BPs treatment, BPs exposure, initial periapical index (PAI) and occlusal restoration. Survival curves were constructed using Kaplan-Meier analysis, with extraction serving as the end-point. RESULTS: In total, 65 patients with 109 root canal-treated teeth who were taking BPs were included. At 60 months, data from 57 patients (52F, 5M; median age 65.7 ± 8.6 years) who had undergone 96 root canal treatments were analysed (drop-out rate = 16.9%). The survival rate was 85%, and the success rate was 76%. The control group consisted of 46 patients (21F, 25M; median age 60.3 ± 7.2 years) who had undergone 102 root canal treatments. The survival rate was 88%, with 12 teeth lost during follow-up. The success rate was 73%. In the BP group, 55 teeth were restored normally (OC group) and 41 teeth were restored at the tissue level (TL group). No difference in the success or survival rate was observed between the BP and control groups (P > 0.05). Univariate Kaplan-Meier analysis revealed that only tooth type significantly affected survival status in the BP group. The analysis revealed the clinical relevance of smoking, tooth location and initial PAI on patients' health status (P < 0.05). CONCLUSION: Root canal treatments and post-endodontic restoration with tissue-level filling procedures represent a safe approach for severely damaged teeth in patients receiving BPs having comparable results to root filled teeth restored with occlusal contacts and to the control group.

Differential diagnosis between a granuloma and radicular cyst: effectiveness of magnetic resonance imaging.

AIM: To investigate the diagnostic reliability and accuracy of magnetic resonance imaging (MRI) to differentiate periapical lesions of endodontic origin and to compare the results with histopathological information. METHODOLOGY: The radiolucent periapical jaw lesions of 34 patients, which were surgically enucleated, were investigated by two radiologists using MRI, based on the same six criteria, to categorize the lesions as granulomas, radicular cysts or others. After apicoectomies, two oral pathologists (blinded to the radiologist's diagnoses) analysed all specimens by referring to seven specific parameters and diagnosed the specimens as granulomas, radicular cysts or other conditions. The inter-rater agreements between the radiologists and pathologists in terms of MRI and histological diagnoses, respectively, along with the discriminant power of the adopted criteria and the accuracy of the MRI assessments compared with the histopathological results, were calculated. Cohen's kappa test was adopted to examine inter-rater agreement between the two radiologists and two pathologists. Guttman's lambda coefficient (λ6 ) was used to evaluate the internal consistency of the items used for the differential diagnosis by radiologists. The accuracy resulted from a receiver operator characteristic (ROC) analysis. RESULTS: A strong inter-rater reliability was observed between the two radiologists (k-statistic = 0.86, P = 0.0001) and the two pathologists (k-statistic = 0.88, P = 0.0001). The internal consistency of the diagnostic items was 0.605 for cysts and 0.771 for granulomas. The accuracy (true positives plus true negatives) of the radiologists was greater than that of the pathologists based on analysis (area under the curve = 0.87 and 0.91, respectively). CONCLUSIONS: The reliability and accuracy of MRI were high and comparable to histopathological reliability, highlighting the usefulness of this noninvasive technique as a pre-treatment diagnostic method for periapical endodontic lesions.

Calcium silicate/calcium phosphate biphasic cements for vital pulp therapy: chemical-physical properties and human pulp cells response.

OBJECTIVES: The aim was to test the properties of experimental calcium silicate/calcium phosphate biphasic cements with hydraulic properties designed for vital pulp therapy as direct pulp cap and pulpotomy. METHODS: CaSi-αTCP and CaSi-DCDP were tested for ion-releasing ability, solubility, water sorption, porosity, ability to nucleate calcium phosphates, and odontoblastic differentiation­alkaline phosphatase (ALP) and osteocalcin (OCN) upregulation­of primary human dental pulp cells (HDPCs). RESULTS: The materials showed high Ca and OH release, high open pore volume and apparent porosity, and a pronounced ability to nucleate calcium phosphates on their surface. HDPCs treated with CaSi-αTCP showed a strong upregulation of ALP and OCN genes, namely a tenfold increase for OCN and a threefold increase for ALP compared to the control cells. Conversely, CaSi-DCDP induced a pronounced OCN gene upregulation but had no effect on ALP gene regulation. CONCLUSIONS: Both cements showed high biointeractivity (release of Ca and OH ions) correlated with their marked ability to nucleate calcium phosphates. CaSi-αTCP cement proved to be a potent inducer of ALP and OCN genes as characteristic markers of mineralization processes normally poorly expressed by HDPCs. CLINICAL RELEVANCE: Calcium silicate/calcium phosphate cements appear to be attractive new materials for vital pulp therapy as they may provide odontogenic/dentinogenic chemical signals for pulp regeneration and healing, and dentin formation in regenerative endodontics.

Sex differences in pudendal somatosensory evoked potentials.

BACKGROUND: Somatosensory evoked potentials (SEPs) of the pudendal nerve are a well-established diagnostic tool for the evaluation of pelvic floor disorders. However, the possible influence of sex differences on response latencies has not been established yet. The aim of this study was to standardize the procedures and to evaluate possible effects of gender differences on anal and penile/clitoral SEPs. METHODS: The anal and dorsal penile/clitoral SEPs were recorded in 84 healthy subjects (40 males and 44 females; mean age 47.9 ± 16.6 years, range 16-81 years; mean height 168.3 ± 20.3 cm, range 155-187 cm). Pudendal SEPs were evoked with a bipolar surface electrode stimulating the clitoris or the base of the penis and the anal orifice and recorded using scalp electrodes. The latency of the first positive component (P1) was measured. The effect and possible interaction of (a) stimulation site and (b) gender on the two variables was explored by multivariate analysis of variance (MANOVA). RESULTS: The examination was well tolerated and a reproducible waveform of sufficient quality was obtained in all the subjects examined. In the female subjects, a mean cortical P1 latency of 37.0 ± 2.6 and 36.4 ± 3.2 ms for anal and clitoral stimulation, respectively, was found. In the male subjects, the cortical latencies were 38.0 ± 3.5 ms for the anal stimulation and 40.2 ± 3.7 ms for the penile stimulation. At MANOVA, a statistically significant main effect of stimulation site and gender as well as a significant interaction between the two variables was found. CONCLUSIONS: Anal and dorsal penile/clitoral SEPs represent a well-tolerated and reproducible method to assess the functional integrity of the sensory pathways in male and female subjects. Obtaining sex-specific reference data, by individual electrophysiological testing, is highly recommended because of significant latency differences between males and females, at least as far as penile/clitoral responses are concerned.

Self-assessed bruxism and phobic symptomatology.

AIM: The aim of this observational study was to compare two samples of patients (identified, from a previous survey carried out in 2007, as self-assessed bruxers and not) on the basis of the presence of anxious/phobic symptoms, general and linked to an oral surgery. METHODS: Forty-three bruxers and 207 non-bruxers were identified; among these last ones a sub-sample of 89 subjects was randomly selected as control and analyzed. The instruments for data collecting were two self-administered psychological questionnaires: STAI-Y1, Phobia Scale by Marks-Sheehan, and supplementary items on specific dental fear/phobia. RESULTS: No significant differences were observed for age, gender and occupation data but interestingly bruxers are significantly more represented among widows/divorced and graduated in comparisons with non-bruxers. Alcohol consumers were more frequent in bruxers than in non-bruxers (55.8% and 12.4%, respectively; P=0.0001). Global anxiety (P=0.02), agoraphobia, claustrophobia, pathophobia, social phobia (P<0.05), are more frequent in bruxers as also a suffocation feeling (P=0.02). The severity of behaviours that aim to avoid the same situations that causes phobias is low and similar in the two groups. CONCLUSION: The involuntary habit of clenching is, in our opinion, reported by the patients who control their anxiety/phobias without avoiding behaviours, increasing the muscular activity at a level relevant to bruxism.

Activity and expression of nitric oxide synthase in rat bladder after sacral neuromodulation.

The aim of our study is to investigate the effects of chronic sacral neuromodulation on Nitric Oxide (NO) metabolism in the rat bladder. 26 female Sprangue-Dawley rats were considered: group I, normal control rats; group II, a sham treatment, in whom catheters for electrical stimulation were placed in the S1 foramen bilaterally and left in place for 21 days, without performing neuromodulation; group III in whom electrical sacral neuromodulation was performed for 21 days. Finally a cystectomy was performed and the bladder biopsy specimens were sent for immunostaining with n-NOS and i-NOS. Morphological and immunohistochemical analysis was carried out, and evaluated in urothelial cells, endothelial cells and muscle fibers of the muscularis propria. Differences between the 3 groups were analyzed by Student Newman-Keuls test. We could observe that urothelial and endothelial i-NOS (37.00+/-4.69 and 59.00+/-7.42 respectively) and urothelial n-NOS (36.80+/-7.85) expression are significantly increased in neuromodulated rats, compared to groups 1 and 2 (p<0.005). In conclusion, the increase of i-NOS expression on endothelial cells after sacral neuromodulation could be in some way related to angiogenetic responses in the microvascular structures; the increase of n-NOS and i-NOS expression on urothelial cells can suggest that NO is able to influence the plasticity of bladder response, inducing the release of messengers within the urothelium. This study can therefore improve our understanding of the mechanisms of sacral neuromodulation on chronic bladder dysfunction; further studies will need to better demonstrate the role of angiogenesis in the bladder after sacral neuromodulation and to investigate the effects of neuromodulation in rats with chronically induced bladder dysfunction.

Prescriptions of NSAIDs to patients undergoing third molar surgery : an observational, prospective, multicentre survey.

BACKGROUND AND OBJECTIVES: Surgical extraction of an impacted third molar is generally followed by acute post-operative pain that has been shown to be primarily inflammatory. Thus, use of NSAIDs in this context is appropriate and has been shown to be effective. Several drugs are employed for this purpose, but no information exists on the reasons why preference is given to one rather than another. The principal objective of this study was to evaluate the pattern of administration of NSAIDs in patients undergoing surgery for impacted third molar extraction. The study also aimed to collect information on the efficacy, onset and duration of the analgesic effect of routinely prescribed NSAIDs and to assess the duration of treatment with these drugs and their tolerability. METHODS: This was an observational, multicentre, prospective survey. A total of 616 patients (38% male and 62% female) from the Italian Stomatology Clinics of the Universities of Bologna, Brescia, Cagliari, Chieti, Pavia, Pisa, Siena and Varese and from the Department of Oral and Maxillo-Facial Surgery of Semmelweis University, Budapest, were eligible for the study. Patients were evaluated over the 7 days following surgical extraction. NSAIDs were prescribed according to the normal prescribing habits of the centre and physician involved. The main outcomes of interest in the survey were the efficacy, onset and duration of analgesic effect, duration of therapy, and tolerability of the NSAIDs prescribed. RESULTS: Nimesulide was the most prescribed NSAID (68%), followed by diclofenac, ketoprofen and ibuprofen. Because of the low proportion of patients receiving other NSAIDs, these patients were considered a single treatment group for evaluation purposes. Nimesulide, especially when given before patients started experiencing pain after surgery, was more effective than other NSAIDs in reducing the severity of pain on the day of surgery, in delaying the time to maximum intensity of pain, in providing complete pain relief and in prolonging the duration of analgesic effect on the day of surgery. These results are consistent with the known anti-inflammatory and analgesic actions of nimesulide and with the important role of inflammation in the onset of pain after this type of surgery. CONCLUSION: These results confirm nimesulide as an effective reference drug for the treatment of post-operative dental pain and show that it has a positive benefit/risk profile in this setting.

Dental phobia in dentistry patients.

AIM: This study evaluated the presence of current and general phobia and anxiety symptoms in periodontology patients just before treatment in relation to specific dental fears and to general health status and quality of life. METHODS: The study population was all consecutive outpatients attending the Periodontics and Implantology Services, School of Dentistry, University of Bologna, over a 12-month period in 2007. Data collection instruments were psychological questionnaires (State-Trait Anxiety Inventory [STAI]-Y1, Marks-Sheehan Phobia Scale [MSPS], World Health Organization Quality of Life [WHOQOL] short form) plus supplementary items investigating specific dental fears, patient's dental history, and the dentist's clinical assessment of the patient. RESULTS: In all, 250 consecutive patients were recruited. Most (86%) presented with very mild anxiety and phobia symptoms; 13.2% and 13% presented with psychological symptoms of anxiety and phobia, respectively, independently of those subjects with specific dental fears who were significantly younger. The most common dental fears were fear of pain (48.8%) and of receiving an injection (29.9%). The patients' quality of life did not appear to be affected by these fears. CONCLUSIONS: In the dental outpatients seeking treatment for moderate-to-severe dental pathology at a university periodontics and implantology clinic and referring good general health and psychosocial functioning, levels of anxiety and phobia were usually low or absent; but when present, they were independent of ascertained specific dental fears.

Delayed onset infections after lower third molar germectomy could be related to the space distal to the second molar.

The onset of delayed infection after lower third molar germectomy is influenced by the amount of distal space. This retrospective study aimed to determine whether the incidence of delayed onset infection is related to the space distal to the second molar. The ratio between the distal space and the crown width, measured according to the Ganss protocol on panoramic radiographs, was obtained for 218 surgical germectomies performed for orthodontic reasons in 134 patients. A delayed onset infection occurred following 20 germectomies at between 2 and 8 weeks after surgery; purulent exudates from the alveolus and swelling were present. In 16 of the 20 cases of infection, a Ganss ratio of <0.5 showed the almost complete absence of space distal to the second molar. This study found that the distal space was significantly and inversely correlated with delayed onset infection (P=0.004). From a clinical point of view, it is important for the surgeon to be aware that a higher Ganss ratio may indicate that a delayed onset infection is less likely to occur and that a lower Ganss ratio could indicate a greater likelihood of this type of infection, so that the patient can be properly informed.

Periodontal disease as a risk factor in pregnancy.

There is growing evidence that periodontal disease represents a risk factor for preterm delivery and premature membrane rupture. To prevent an oral inflammatory process evolving into a full-blown form of periodontitis, with possible severe repercussions on pregnancy outcome following systemic spread, future mothers should receive regular professional oral hygiene care throughout pregnancy.

Structural features of latex gloves in dental practice.

The aim of this study was to define from a morpho-structural point of view, using scanning electron microscopy, the features of various types of disposable latex gloves commonly used in Italian dental practice (Biogel D, Trend, Pagni, J&J, Latechnics, Pehasoft, Bantex). None of the brands examined was free from morphological flaws; however, while in some of these only slight depressions were found (Biogel D, Trend), in others (Latechnics, Bantex) there was a marked lack of homogeneity in the latex structure or real holes (Pehasoft). This study emphasizes the current difficulties faced by dentists in the search for safe working conditions.

Magnetic stimulation of the spinal accessory nerve: normative data and clinical utility in an isolated stretch-induced palsy.

We report the clinical and electrophysiological findings of isolated stretch-induced accessory nerve palsy obtained by using conventional technique compared to magnetic stimulation at the base of the skull. The same methods of magnetic stimulation were applied in 10 healthy volunteers, to determine normal limits of amplitude and latency of the motor responses. The clinical features of the isolated spinal accessory nerve palsy are weakness of the sternocleidomastoid muscle and of the three portions of trapezius muscle. Most commonly reported etiologies include surgical manipulation and excision in the posterior triangle of the neck. Less frequently the cause is represented by radiation procedures, shoulder traction, penetrating, blunt or stretch injuries; this last etiology is extremely rare. The use of conventional electrophysiological methods to evaluate injuries of the nerves leaving the base of the skull is limited by the difficulty in obtaining an adequate electrical surface stimulation necessitating the use of needle electrodes. Moreover, conventional electrical stimulation often causes significant discomfort to the patient. The magnetic coli stimulation at the base of the skull is a new alternative painless technique that permits to elicit motor responses, by stimulating deeply situated nerves and, in particular, the accessory nerve, resulting as a useful electrodiagnostic tool.

Motor evoked potentials recorded from external anal sphincter by cortical and lumbo-sacral magnetic stimulation: normative data.

Electrophysiological activation of the motor pathways can be obtained by electrical or magnetic stimulation. The latter has the great advantage of being painful and able to stimulate deeply situated nervous structures. Only a few reports describe responses obtained from pelvic floor muscles and external anal sphincter (EAS) by transcranial and lumbo-sacral magnetic stimulation. Our purpose is to present normative data of motor evoked responses from EAS in a group of healthy subjects (age range 19-80 years) using a standardized protocol of magnetic stimulation. Nine females and 7 males, with a mean age of 52.63 years, were included in this study. They had no known neurological and gastrointestinal disease. Magnetic shocks were delivered by a Magstim 200 (Novametrix) and a circular coil, centered on the vertex and on the lumbo-sacral region. Electromyographic recordings were taken from EAS using needle electrodes. The cortical magnetic stimulation was performed in two conditions: at rest and during a mild contraction of pelvic floor muscles. The mean values of motor evoked potentials (MEPs) latencies after cortical stimulation were 26.92+/-3.01 ms at rest and 23.31+/-2.70 ms during facilitation. Motor latency after lumbo-sacral root stimulation was 6.09+/-1.43 ms. The MEPs from EAS are easily obtained and stably reproducible in normal subjects. It can be suggested also as a useful adjunct in the assessment of faecal incontinence.

Hand versus ultrasonic instrumentation in the removal of endotoxins from root surfaces in vitro.

The goal of this study was to determine whether ultrasonic scalers are as effective as curettes in providing fibroblast attachment to the scaled root surfaces. Extracted, peridontally involved teeth were cut along the sagittal plane; then one half of the root was curetted, the other half ultrasonically scaled. In addition, monkey kidney fibroblasts were suspended in a petri dish containing root fragments of the tooth halves. At the same time, control dishes without fragments were mounted. All dishes were treated with radioisotopic techniques. There was no significant difference in fibroblast growth between peridontally involved root surfaces treated using curettes or ultrasonic scalers. Both treatments caused the roots to lose their toxicity. The limitations of ultrasonic scalers in terms of shape, size and awkward handling need to be considered when choosing the approach that best suits each case.

[Utility of electrophysiologic study using the blink reflex and brainstem evoked potentials for the evaluation of the course of uremic polyneuropathy]. / Utilità dello studio elettrofisiologico mediante blink reflex e potenziali evocati del tronco encefalico (BAEPS), per la valutazione dell'evoluzione della polineuropatia uremica.

On the present study the authors evaluate the utility of electrophysiologic examination in uraemic polyneuropathy. A group of 19 uraemic patients in chronic dialysis underwent the Blink reflex and BAEPSs study to evaluate the alterations of nervous pathways. The results obtained were compared with those of a group of 10 healthy patients comparable for age and sex. The electrophysiologic parameters have been statistically compared with the plasma levels of vit. B12. folic acid, PTH and beta-2-microglobulin. The results show a significant difference of uremic patients compared with the healthy ones for the Blink reflex (ipsilateral and contralateral R2 responses). Also BAEPSs show significant alterations in the uraemic group (latencies of the III, V components). A statistically significantly inverse correlation is present between folic acid values and blink reflex R1 and R2 responses. Therefore our study shows the existence of a combined degeneration of central and peripheral nervous pathways in chronic uraemic patients. We believe that the decrease in folic acid concentration found in our study may be one of the causes of the beginning and then of the worsening of neurologic damage.

Removing high-risk impacted mandibular third molars: a surgical-orthodontic approach.

The authors present a surgical-orthodontic approach to the extraction of impacted mandibular third molars that have a close anatomical relationship between the root and the mandibular canal. They explain that this procedure, in selected cases, decreases the risk of neurological complications and facilitates extraction.

Management of bilaterally impacted mandibular second and third molars.

BACKGROUND: The authors present an interdisciplinary approach to treating bilateral impaction of mandibular second molars. CASE DESCRIPTION: A 22-year-old man had a bilateral deep horizontal impaction of his mandibular second molars. The mandibular third molars lay above and parallel to the second molars. After an orthodontic assessment, the authors decided to distally upright the third molars, remove them and then orthodontically reposition the second molars if they were not ankylosed. This combined orthodontic-surgical approach was successful. CLINICAL IMPLICATIONS: This case illustrates the importance of strong cooperation among various specialists to establish the optimal comprehensive treatment plan.

In vitro growth of periodontal fibroblasts on treated cementum.

The aim of the present study was to assess the ability in vitro of phosphoric and citric acids, applied on human root cementum, to neutralize noxious plaque and calculus and to allow the growth of human gingival fibroblasts. Fibroblasts grown on cementum treated with phosphoric acid appeared typically elongated and aligned parallel to the root surface. Fibroblasts grown on cementum treated with citric acid, in both normal and periodontally diseased teeth, lost their elongated shape, acquiring polygonal borders with irregular cytoplasmic extrusions, and the cell density was significantly lower. These findings suggest that phosphoric acid cleaning of both normal and diseased root surfaces may result in an oriented, high rate of fibroblastic growth with more effective periodontal cellular proliferation than that observed after citric acid treatment.

Atmospheric contamination during dental procedures.

The aim of this study was to evaluate the level of aerosol pollution following dental procedures performed in 15 sessions with an ultrasound scaler and a bicarbonate cleaner. The air contamination was measured by means of the Surface Air System method and the "plate" method (Air Microbial Index). Each colony-forming unit per cubic meter of air was allotted a unit value for statistical analysis. The data were then compared with the hygienic assessments made in previous studies. The results showed that the initial environmental conditions in a dental office initiated at the level of mediocre, then became very bad during dental procedures, and fell between mediocre and very bad at the end of the procedures.