Low energy Helium-Neon laser in the prevention of oral mucositis in patients undergoing bone marrow transplant: results of a double blind randomized trial.

PURPOSE: To evaluate the efficiency of Helium-Neon (He-Ne) laser in the prevention of oral mucositis induced by high dose chemoradiotherapy before autologous bone marrow transplantation (BMT). METHODS AND MATERIALS: Between 1993 and 1995, 30 consecutive patients receiving an autologous peripheral stem-cell or bone marrow transplant (BMT) after high dose chemoradiotherapy were randomized to possibly receive prophylactic laser to the oral mucosa after giving informed consent. Chemotherapy consisted of cyclophosphamide, 60 mg/kg intravenously (I.V.) on day (d)-5 and d-4 in 27 cases, or melphalan 140 mg/kg I.V. on d-4 in three cases. Total body irradiation (TBI) consisted of 12 Gy midplane dose in six fractions (4 Gy/day for three days). He-Ne laser (632.8 nm wavelength, power 60 mW) applications were performed daily from d-5 to d-1 on five anatomic sites of the oral mucosa. Oral examination was performed daily from d0 to d + 20. Mucositis was scored according to an oral exam guide with a 16 item scale of which four were assessed by the patients themselves. Mean daily self assessment scores for oral pain, ability to swallow and oral dryness were measured. A daily mucositis index (DMI) and a cumulative oral mucositis score (COMS) were established. Requirement for narcotics and parenteral nutrition was recorded. RESULTS: The COMS was significantly reduced among laser treated (L+) patients (p = 0.04). The improvement of DMI in L+ patients was also statistically significant (p < 0.05) from d + 2 to d + 7. Occurrence and duration of grade III oral mucositis were reduced in L+ patients (p = 0.01). Laser applications reduced oral pain as assessed by patients (p = 0.05) and L+ patients required less morphine (p = 0.05). Xerostomia and ability to swallow were improved among the L+ patients (p = 0.005 and p = 0.01, respectively). Requirement for parenteral nutrition was not reduced (p = NS). CONCLUSION: Helium-Neon laser treatment was well tolerated, feasible in all cases, and reduced high dose chemoradiotherapy-induced oral mucositis. Optimal laser treatment schedules still needs to be defined.

The use of a resorbable membrane in mucogingival surgery. Case series.

A surgical technique involving a resorbable membrane was used to treat 3 to 7 mm localized human buccal recessions on 10 consecutive patients. The exposed root surface was scaled and a trapezoidal mucoperiosteal flap was elevated after de-epithelization of the papillae. The space between the root and the membrane was created using a bur to form a concavity on the root and by bending the membrane with a suture. The flap was positioned as coronally as possible covering the membrane. The sutures were removed 15 days postsurgery and tetracycline therapy prescribed for 10 days. The results were evaluated at 12 months. The surgical procedure resulted in a significant reduction in recession (2.9 mm +/- 1.3) as well as a gain in attachment (3.4 mm +/- 2.1). Calculation of mean root coverage was 59.6%. There was no significant change of the keratinized tissue width. For therapeutic reasons, re-entry was performed in 2 cases: newly formed tissue was observed on the previously exposed roots. Guided tissue regeneration using a resorbable membrane appears to provide good results in cases of localized buccal recession.

Effect of masticatory cycles on tooth compression and resultant leakage of amalgam retrofills.

This study was carried out to investigate the effect of changes in tooth structure due to masticatory cycles on amalgam retrofillings performed to different cavity depths. Forty upper maxillary first molars were tested. In the obturated palatal root apical amalgam was inserted to different depths (1.5 and 3 mm). Eight casts were built, each having four sample molars. To block the teeth, the vestibular roots were embedded in resin (palatal root was left free). The eight remaining retrofilled teeth served as controls and were not submitted to occlusal forces. A mechanical device to simulate masticatory cycles subjected the teeth to 500,000 to three million cycles. Leakage was assessed from dye penetration observations. The values of microleakage were analyzed and compared, and strain gauges were used to assess structural modifications to the tooth. The leakage of all retrofilled obturations increased in correlation with the number of masticatory cycles. At three million cycles, root length compression was 0.3 +/- 0.02%. Leakage was significantly less for the deeper cavity preparations at all stages. This in vitro study suggests a significant effect by root compression due to masticatory loads on the leakage of retrofilled amalgam obturations.

In vitro cytotoxicity of one-step dentin bonding systems.

The cytotoxicity of resinous monomers may vary on mixing, calling into question the cytotoxicity of the new dentin bonding agents that are mixed in a single vial. The cytotoxicity of fourth and fifth generation dentin bonding agents was compared in vitro. All-Bond 2, One-Step, Scotchbond Multi-Purpose, Scotchbond One, Syntac, Syntac Single Component, Tenure, and Tenure Quick were tested uncured. The cytotoxicity of several dilutions of fourth generation dentin primer, dentin bonding agent, dentin primer + dentin bonding agent, and fifth generation single component products diluted at 10(-1) to 10(-8) in culture medium was recorded with a MTT assay on L929 fibroblasts. Only one synergistic (increased cytotoxicity after mixing primer and bonding agent) cytotoxic effect was observed with Tenure at 10(-5) dilution. An antagonistic effect (decreased cytotoxicity after mixing primer and bonding agent) was observed with All-Bond 2 between 10(-4) and 10(-8) dilutions. Scotchbond and Syntac fifth generation dentin bonding agents were less cytotoxic than their fourth generation counterparts. All-Bond and Tenure fifth generation dentin bonding agents were more cytotoxic than their fourth generation counterparts only in low dilutions. Clinical studies should confirm these good results, because no dramatic synergistic cytotoxic effect could be detected.

Low versus high pressure for in vitro determination of hydraulic conductance of human dentine.

The purpose of this study was to evaluate the effect of applied pressure and measurement time on the in vitro measurement of hydraulic conductance of human dentine. Dentine slices were prepared from 50 third molars. Water was forced through the slices under a constant hydrostatic pressure. Five pressures were tested: 1.3 kPa (n = 10), 13.3 kPa (n = 10), 26.6 kPa (n = 10), 40 kPa (n = 10) and 53.3 kPa (n = 10). The volume that went through the slices was recorded every 10 min for 3 h. The volume, the fluid flow rate and the hydraulic conductance under the five pressures were compared. The volume increased with time and pressure. The fluid flow and hydraulic conductance decreased with time under 13.3, 26.6 and 40 kPa, but remained constant under 1.3 and 53.3 kPa. Used of a low pressure (1.3 kPa) may permit water to pass through dentinal tubules without disturbing intratubular contents. Medium pressures (13.3, 26.6, 40 kPa) seemed to disturb tubule contents progressively, resulting in decreased fluid flow and therefore a decreased hydraulic conductance with time. Under these pressures, the calculated values of hydraulic conductance may be unreliable because they are time-dependent. High pressure (53.3 kPa) seemed to pack the tubule contents against intratubular resistances immediately, resulting in low fluid flows and low hydraulic conductances.

Effects of pulsatile versus non-pulsatile pulpal pressure simulations on diffusional transport across human dentine in vitro.

The influence of a simulated pulsatile pulpal pressure on the diffusion of NaCl through slices of human dentine (n = 12) was evaluated in vitro. The average hydraulic conductance of the slices of dentine was 0.0131 +/- 0.0031 microliter/cm2 per min per cmH2O(x +/- SD). A 1 mol/l NaCl solution was placed on one side of the slices of dentine and deionized water on the other side. The time needed to reach a steady state and the quantity of NaCl that diffused through the slice were successively measured on the same slice of dentine, under three conditions: without pressure simulation, with a static pressure of 1.5 kPa, and with a pulsatile pressure varying from 1.2 to 1.8 kPa. The pressure was applied to the deionized water. When a static pressure was applied, the time required to reach a steady state increased from 24 to 30 h. When a pulsatile pressure was applied the time required to reach a steady state decreased from 24 to 12 h. No statistically significant difference was found between the quantity of NaCl that had diffused when the steady state was reached.

Eugenol diffusion through dentin related to dentin hydraulic conductance.

OBJECTIVES: The purpose of this study was (1) to find an easy way of evaluating the concentration of eugenol in cell culture fluids; (2) to confirm the relationship between the concentration and the cytotoxicity of eugenol in vitro; (3) to evaluate the cytotoxicity of four temporary eugenol-based filling materials: IRM, super EBA, Kalsogen and zinc oxide-eugenol cement; and (4) to establish a relationship between dentin permeability, eugenol diffusion and cytotoxicity. METHODS: (1) The concentration of eugenol was measured with a spectrofluorimeter; (2) the cell viability of L 929 cells cultivated for 24 h with eugenol-containing medium was evaluated by the MTT assay; (3) after measurement of hydraulic conductance, occlusal cavities in human teeth in vitro were filled with the restorative materials. The cytotoxicity was measured with undiluted test medium and with various dilutions in culture medium; (4) after Lp measurement, the eugenol concentration in the media in the pulp chamber that diffused from IRM and 10(3) mol/l eugenol solution was measured. RESULTS: (1) A proportional relationship (p = 0.001 and r = 1) was found between the concentration of eugenol; (2) eugenol started to be cytotoxic at 10(-5) mol/l and killed 95% of the cells at 10(-3) mol/l; (3) zinc oxide-eugenol cement was the most cytotoxic filling material when tested with the 1:100 dilution; (4) a significant relationship was found between Lp and cytotoxicity (p = 0.04) depending on the dilution of the test medium. A significant relationship was found between Lp and eugenol diffusion from a 10(-3) mol/l solution (p = 0.03) but not between Lp and eugenol diffusing from solid IRM (non significant). SIGNIFICANCE: Eugenol diffusion from zinc oxide-eugenol cement appears to depend more on the role of hydrolysis of eugenol from zinc oxide-eugenol cement than on dentin permeability.

In vitro cytotoxicity of dental adhesive systems under simulated pulpal pressure.

OBJECTIVES: Most of the devices used to evaluate the cytotoxicity of resin-based composites in vitro use a dentin barrier test. However, it is difficult to obtain the number of freshly extracted teeth, all on the same day, that is necessary for powerful statistical analysis. Tooth cryopreservation provides a way to build up a supply of teeth. This in vitro study compared cryopreserved teeth and freshly extracted teeth in an evaluation of the cytotoxicity of resin-based composites. In addition, this study also evaluated the effects of pulsatile pressure and the importance of dentin permeability on the cytotoxic response to bonding resins. METHODS: Forty freshly extracted and forty cryopreserved third molars were used. A standardized Class I cavity was prepared within the dentin. The hydraulic conductance of each tooth was recorded. The cavities were filled either with Scotchbond Multi-Purpose Plus and Z 100 (3M Dental Products) or with Optibond and Herculite (Kerr). A plexiglas device was designed to permit 24 h long contact between culture medium and the roof of the pulp chamber while a pulsatile pulpal pressure was simulated. The viability of L 929 cells cultured with a control medium and evaluated by an MTT assay was compared to that of L 929 cells cultured with medium which remained for 24 h in contact with the pulp chamber of restored teeth. A three-way ANOVA was used to compare the cytotoxicity among the different groups. A simple least-squares linear regression was used to seek a relationship between the hydraulic conductance of dentin and the cytotoxicity of composite restorative materials. RESULTS: No significant differences in cytotoxicity were found between the freshly extracted teeth and the cryopreserved teeth (p = 0.53). The cytotoxicity of the resin adhesives was statistically higher when a pulsatile pulpal pressure was simulated (p = 0.04). A significant relationship was found between the hydraulic conductance of dentin and the cytotoxicity of resin-based composites (p = 0.02). SIGNIFICANCE: Cryopreserved teeth can be used for in vitro evaluation of the cytotoxicity of resin adhesives. Pulsatile pulpal pressure simulations increased the in vitro cytotoxicity of the tested materials.

The effect of cavity restoration variables on odontoblast cell numbers and dental repair.

OBJECTIVES: Dentinal repair following cavity restoration is dependent on several parameters including the numbers of surviving odontoblasts. The purpose of this study was to examine the effects of cavity cutting and restoration treatments on post-operative odontoblast numbers. METHODS: 353 Standardised non-exposed rectangular Class V cavities, were cut into the buccal dentin of intact 1st or 2nd premolar teeth of 165 patients, aged between nine and 25 years of age. Composite cavity restorations with various etching treatments were compared with resin-modified glass ionomer cements, enamel bonding resins, as well as polycarboxylate, calcium hydroxide, and zinc oxide eugenol materials. Following tooth extraction (20-381 days) for orthodontic reasons, the area of the reactionary dentine and the area of the odontoblasts was measured histomorphometrically. RESULTS: Odontoblast numbers and dentine repair activity were found to be influenced more by cavity restoration variables, than the choice of cavity filling materials or patient factors. The most important cavity preparation variable was the cavity remaining dentine thickness (RDT); below 0.25mm the numbers of odontoblasts decreased by 23%, and minimal reactionary dentine repair was observed. CONCLUSIONS: Odontoblast injury increased as the cavity RDT decreased. In rank order of maintaining odontoblast numbers beneath restored cavities with a RDT below 0.5mm, and using calcium hydroxide for comparison; calcium hydroxide (100%), polycarboxylate (82.4%), zinc oxide eugenol (81.3%), composite (75.5%), enamel bonding resin (49.5%) and RMGIC (42.8%). The vitality and dentine repair capacity of the pulp is dependent on odontoblast survival. Variations in the extent of odontoblast injury caused during operative procedures, may be the major underlying reason for the success or failure of restorative treatments.

Human odontoblast cell numbers after dental injury.

OBJECTIVES: The purpose of this study was to measure the changes in odontoblast cell numbers in response to cavity restoration variables and patient factors, and the effect these factors have on dental repair by tertiary dentinogenesis. The number of vital odontoblasts is a critical factor for pulpal repair following restorative surgery, and yet little information is available on these cell numbers. METHODS: Class V non-exposed cavities were prepared in the buccal surface of intact first or second premolar teeth of 27 patients, between 9 and 17 years of age. Following tooth extraction (28-163 days) the area of reactionary dentine and the area of the odontoblasts were measured histomorphometrically. RESULTS: Patient factors, as well as cavity preparation and restoration variables, had little effect on the numbers of odontoblasts per pulpal unit area. However, the age of the patient did appear to have an effect on the reactionary dentine secretory capacity of odontoblasts per unit area, and on the relative number of odontoblasts beneath cut dentinal tubules. CONCLUSIONS: Odontoblast cell numbers were maintained following the preparation of cavities cut into dentine with a 0.5mm residual dentine thickness. The repair capacity of the pulp-dentine complex would appear to be age dependent, this may explain differences in the success of various restorative treatments between patients.

Relationship between dentine hydraulic conductance and the cytotoxicity of four dentine bonding resins in vitro.

OBJECTIVES: Dentine modifies pulpward diffusion of monomers leaching from restorative materials. Thus, remaining dentine thickness must be taken into account during in vitro cytotoxicity tests. This in vitro study was designed to determine the influence of dentine permeability on the outcome of a cytotoxicity test. METHODS: Dentine slices were made from 36 human third permanent molar teeth. The 36 dentine slices were divided into two groups according to their hydraulic conductance: high or low hydraulic conductance. The cytotoxicity of four dentine bonding agents of similar cytotoxicity was tested on dentine slices from each group. Four dilutions of the experimental culture medium were tested: undiluted, 1:2, 1:10 and 1:100. An analysis of variance was used to compare the cytotoxicity of the dentine bonding agents tested on high versus low hydraulic conductance. RESULTS: The cytotoxicity of the high hydraulic conductance (Lp) group was higher than that of low Lp group when tested with the undiluted test culture medium (p = 0.001). No difference was obtained with the 1:2, 1:10, 1:100 dilutions. CONCLUSIONS: Under the conditions of the study, the dentine bonding resins were more cytotoxic when applied onto dentine slices of high hydraulic conductance.

Odontoblast morphology and dental repair.

OBJECTIVES: To investigate the changes in morphology and activity of pulp odontoblasts in response to cavity restoration variables and patient factors. METHODS: Class V non exposed cavities were prepared in the intact 1st or 2nd premolar teeth of 27 patients, aged between 9 and 17 years-old. Following tooth extraction, the area of reactionary dentine and the area of the odontoblasts were measured using computerised histomorphometry. RESULTS: The cytoplasm to nucleus ratio of the odontoblasts was found to increase beneath cut dentinal tubules, following the secretion of reactionary dentine. However, none of the patient or preparation variables were found to be correlated with changes in the odontoblast cytoplasm to nucleus ratio. CONCLUSIONS: Morphological changes in human odontoblasts is directly related to their capacity to repair dentine injuries and provide pulp protection. Changes in odontoblast morphology reflect secretory activity.

[Laser therapy in the prevention and treatment of mucositis caused by anticancer chemotherapy]. / La laserthérapie dans la prévention et le traitement des mucites liées à la chimiothérapie anticancéreuse.

The appearance of mucositis is a frequent and painful secondary effect of anticancer chemotherapy. Patients who develop oral toxicity during the first course of treatment will almost assuredly show identical side effects during each subsequent course unless the drugs are changed or the doses are lowered. In the absence of an efficacious antidote or preventive prophylaxis for such lesions to date, this report presents the results of a preliminary retrospective non-randomized study of the effect of soft-laser treatments on mucositis in cancer patients receiving combination chemotherapy, including 5-fluorouracil. Iatrogenic mucositis was observed during 43% of 53 chemotherapy cycles in the case control population. Curative laser therapy reduced the time to repair lesions and the rate of therapeutic modifications. For patients who received soft-laser therapy as a preventive measure, the incidence of oral complications was reduced to 6% during 101 cycles of chemotherapy. All of these patients, even those who have encountered mucositis before receiving preventive laser therapy, terminated their cancer therapy as originally scheduled. Well designed and carefully controlled trials will be necessary to define the place of helium-neon laser therapy in the repair and prevention of oral complications due to cancer chemotherapy.

Restorative pulpal and repair responses.

BACKGROUND: Each year, about 90 million new restorations are placed in the United States and 200 million are replaced. Controversy surrounds the pulpal reactions and frequency of bacterial microleakage associated with common restorative materials. The authors investigated and compared pulpal reactions to different types of restorative materials. METHODS: Two hundred seventy-two teeth with standardized rectangular Class V unexposed cavities were restored with resin-based composite bonded to dentin; resin-based composite bonded to enamel; resin-modified glass ionomers, or RMGI; amalgam lined with zinc polycarboxylate, or ZnPC; amalgam lined with calcium hydroxide, or Ca(OH)2; or zinc oxide-eugenol, or ZnOE. Teeth were extracted for orthodontic reasons between 20 and 381 days later. The authors categorized pulpal responses according to standards set by the Federation Dentaire Internationale and the International Organization for Standardization. Bacteria were detected using Brown-Brenn-stained sections. Pulpal responses were evaluated using histomorphometric analysis and analysis of variance statistics. RESULTS: The results showed that RMGI was the best material for preventing bacterial microleakage, and resin-based composite bonded to enamel was the worst. In regard to minimizing pulpal inflammatory activity, ZnOE was the best material and resin-based composite bonded to enamel was the worst. In terms of maximizing odontoblast survival beneath deep cavity preparations, Ca(OH)2, was the best material and RMGI was the worst. CONCLUSIONS: The results show that bacterial microleakage, pulpal injury and repair responses varied widely with different restorative materials. CLINICAL IMPLICATIONS: The authors recommend that RMGI be used to restore teeth with cavities that are shallow to moderate in depth, with the floor of deep cavities being lined with Ca(OH)2 before the teeth are restored with RMGI.

Postoperative pulpal and repair responses.

BACKGROUND: Each year in the United States, the success of 10 million surgically restored carious lesions depends on a favorable tertiary dentin repair response to preparation, restoration and patient factor variables. The authors investigated the relationship between these variables and dentinal response. METHODS: Standardized rectangular Class V restoration preparations were cut into the buccal dentin of intact first or second premolars of 27 patients without exposing the pulp and were restored. The patients were between 9 and 17 years of age. The treated teeth were scheduled for extraction for orthodontic reasons. After tooth extraction, the tertiary dentin was analyzed histomorphometrically. RESULTS: The area of tertiary reactionary dentin was found to be correlated using linear regression analysis of variance with restoration residual dentin thickness (P = .0024), age of the patient (P = .0045), restoration floor surface area (P = .0266) and restoration width (P = .0415). The authors did not find a correlation with the premolar position (P = .0594), sex of the patient (P = .650), pulpal inflammatory reaction (P = .613) or the time elapsed since surgery (P = .531). Restoration with zinc oxide eugenol was found to negatively influence tertiary dentin matrix secretion (post hoc analysis of variance, P = .030). CONCLUSIONS: The age of a patient at treatment, the choice of restorative material and the size of the restoration preparation are all factors that can positively or negatively affect the pulpal repair response. CLINICAL IMPLICATIONS: Age of the patient affects dentin repair capacity and may be a factor in treatment planning decisions. Minimizing the cutting of dentin, especially the width and base of the preparation, reduces the probability of recurrent pulpal complications.

Pulpal inflammatory responses following non-carious class V restorations.

The effects of inflammatory activity following surgical intervention can injure pulp tissues; in severe cases it can lead to pulpal complications. With this article, the authors report on the effects of cavity preparation and restoration events and how they can interact together to reduce or increase the severity of pulpal inflammatory activity in 202 restored Class V cavities. Although some inflammatory activity was observed in the absence of bacteria, the severity of pulpal inflammatory activity was increased when cavity restorations became infected. Zinc oxide eugenol and resin-modified glass ionomer cement prevented bacterial microleakage in cavity restorations, with no severe inflammatory activity observed with these materials. Bacteria were observed in cavities restored with enamel bonding resin and adhesive bonded composites and were associated with severe grades of inflammatory activity. The cavity remaining dentin thickness influenced the grade of inflammatory activity. In the absence of infection, the grade of inflammatory activity decreased after 20 weeks post-operatively. In the presence of infection, the grade of pulpal inflammation remained stable until a minimum of 30 weeks had elapsed.

Effects of desensitizing agents on human dentin permeability.

PURPOSE: To compare the in vitro effects of three desensitizing agents on hydraulic conductance of human dentin: Protect (n = 10), Gluma Desensitizer (n = 10), MS Coat (n = 10) (Pain-Free in the USA). MATERIALS AND METHODS: Dentin discs were prepared from 40 freshly extracted normal human third molars. The pulpal side of the dentin discs was etched with 37% phosphoric acid for 15 s and then rinsed under tap water. The coronal side was sequentially ground and the dentin discs were sonicated for 30 min. The hydraulic conductance was measured filtering 20% serum in phosphate buffered saline under a pressure of 15 cm H2O. The hydraulic conductance of each dentin specimen was measured before using the desensitizing agent and this value was designated as 100%. Thirty dentin discs were treated, the hydraulic conductance was remeasured and expressed as a percentage of the hydraulic conductance of that specimen before treatment. The teeth were stored for 1 month at 37 degrees C in deionized water and the hydraulic conductance of the 40 dentin discs was recorded again. Ten dentin discs were left untreated to serve as a control. RESULTS: No statistical difference was found between the immediate hydraulic conductance of the three groups after treatment. After 1-month storage, the control group showed a statistically higher hydraulic conductance than the three treated groups. There was no statistical difference between the three dentin desensitizing agents evaluated.