What are the important outcomes in traumatic dental injuries? An international approach to the development of a core outcome set.

BACKGROUND/AIMS: There are numerous treatment options following traumatic dental injury (TDI). Systematic reviews of different treatments are challenging owing to the diversity of outcomes reported between clinical studies. This issue could be addressed through the development and implementation of a agreed and standardized collection of outcomes known as a core outcome set (COS). The aim of this study was to develop a COS for TDI in children and adults. The secondary aim was to establish what, how, when and by whom these outcomes should be measured. MATERIALS AND METHOD: The project was registered with Core Outcomes Measures in Effectiveness Trials (COMET). A web-based survey was developed to capture the opinions of dentists globally as to which outcomes should be recorded. A list of outcomes was entered into a Delphi Survey and scored by an Expert Working Group (EWG). The scoring was repeated, followed by conference calls to discuss, refine and finalize the COS. The EWG split into small groups of subject-specific experts to determine how, when and by whom each outcome would be measured. RESULTS: The questionnaire was completed by 1476 dentists. The EWG identified 13 core outcomes to be recorded for all TDI's. An additional 10 injury-specific outcomes were identified. A table has been produced for each outcome detailing what, when, and how each outcome should be recorded. CONCLUSIONS: A robust consensus process was used to develop an international COS for TDI in children and adults. This includes both generic and injury-specific outcomes across all identified domains.

John G.C. Adams: father of Dental Public Health in Canada.

John Gennings Curtis Adams (1839-1922), Canada's first resident dental missionary, was the father of Dental Public Health in Canada. He established, personally funded and operated the first free dental hospital in North America for poor children and their mothers in Toronto from 1872, three years before the founding of The Hospital for Sick Children; he later became their first dentist of record. He was a visionary zealot for prevention of decay, dental education, and treatment over extraction. Dr. Adams understood that neither parents (rich or poor) nor physicians were aware of the extent of pathosis present in children's mouths. He petitioned individuals, lobbied politicians and unions and pressured dental organizations on the importance of twice-annual school inspections to demonstrate disease so that parents would seek care for their children. He wanted government-funded dental hospitals like his own to treat those who could not afford care. He realized his objectives and his reforms to prevent suffering, as Toronto school inspections began in 1911 and Toronto's first publicly-funded free dental clinic opened in 1913. He was Canada's first dental philanthropist and a visionary for preventive dentistry.

Diabetes Risk Factors and Bone Microarchitecture as Assessed by High-Resolution Peripheral Quantitative Computed Tomography in Adults With Long-Standing Type 1 Diabetes.

OBJECTIVE: To determine whether type 1 diabetes and its complications are associated with bone geometry and microarchitecture. RESEARCH DESIGN AND METHODS: This cross-sectional study was embedded in a long-term observational study. High-resolution peripheral quantitative computed tomography (HR-pQCT) scans of the distal radius and distal and diaphyseal tibia were performed in a subset of 183 participants with type 1 diabetes from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study and 94 control participants without diabetes. HbA1c, skin advanced glycation end products (AGEs), and diabetes-related complications were assessed in EDIC participants with >30 years of follow-up. RESULTS: Compared with control participants (aged 60 ± 8 years, 65% female), EDIC participants (aged 60 ± 7 years, diabetes duration 38 ± 5 years, 51% female) had lower total bone mineral density (BMD) at the distal radius (-7.9% [95% CI -15.2%, -0.6%]; P = 0.030) and distal tibia (-11.3% [95% CI -18.5%, -4.2%]; P = 0.001); larger total area at all sites (distal radius 4.7% [95% CI 0.5%, 8.8%; P = 0.030]; distal tibia 5.9% [95% CI 2.1%, 9.8%; P = 0.003]; diaphyseal tibia 3.4% [95% CI 0.8%, 6.1%; P = 0.011]); and poorer radius trabecular and cortical microarchitecture. Estimated failure load was similar between the two groups. Among EDIC participants, higher HbA1c, AGE levels, and macroalbuminuria were associated with lower total BMD. Macroalbuminuria was associated with larger total area and lower cortical thickness at the distal radius. Higher HbA1c and AGE levels and lower glomerular filtration rate, peripheral neuropathy, and retinopathy were associated with deficits in trabecular microarchitecture. CONCLUSIONS: Type 1 diabetes is associated with lower BMD, larger bone area, and poorer trabecular microarchitecture. Among participants with type 1 diabetes, suboptimal glycemic control, AGE accumulation, and microvascular complications are associated with deficits in bone microarchitecture and lower BMD.

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.

International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth.

Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the task group. The guidelines represent the current best evidence and practice based on literature research and professionals' opinion. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of avulsed permanent teeth.

Clinical relevance of access targets for elective dental treatment under general anesthesia in pediatrics.

OBJECTIVE: To evaluate the clinical relevance of access targets for elective dental procedures performed under general anesthesia at The Hospital for Sick Children in Toronto, Ontario, by assessing incremental changes in the burden of dental disease over wait times for such procedures. METHODS: Children scheduled for elective dental procedures under general anesthesia were assigned a priority according to the dental diagnosis and the medical risk status. Each priority level was defined by a specific diagnostic code and access target (maximum acceptable wait time). The dental records of children who underwent dental procedures with general anesthesia between June 2005 and December 2008 were assessed retrospectively. A novel assessment scale was used to measure the cumulative burden of dental disease during the waiting period. RESULTS: A total of 378 children (age range 10 months to 17 years) met the inclusion criteria. Statistically significant correlations were identified between disease burden and wait times for priority group IV (access target 90 days) (p=0.004), for the entire sample (p<0.001), for children with advanced dental caries and low medical risk (p=0.005), for patients with comorbidities (p=0.036), for healthy patients (p<0.001), for females (p=0.014) and for males (p=0.008). The mean cumulative burden of disease over time did not differ between matched groups with and without comorbidity (p=0.38). CONCLUSIONS: A trend suggestive of increasing burden of dental disease for children with longer wait times for elective dental procedures involving general anesthesia was found, but it was not clinically significant. Refinements in the assessment scale and a better understanding of the natural history of dental disease will likely be useful in developing clinically relevant access targets.

Mineral trioxide aggregate produces superior outcomes in vital primary molar pulpotomy.

PURPOSE: The purpose of this study was to investigate the outcomes of vital primary molar pulpotomy when there is no direct contact between eugenol and the vital pulp. Four pulpotomy techniques were compared: (1) ferric sulfate (FS) pulpotomy; (2) eugenol-free FS pulpotomy; (3) mineral trioxide aggregate (MTA) pulpotomy; and (4) FS/MTA pulpotomy. METHODS: The pulpotomy technique assigned to each molar was determined by random selection. Two blinded, disinterested raters classified each molar into 1 of 3 radiographic outcomes: (1) N=normal molar without pathologic change; (2) Po=pathologic change present, follow-up recommended; (3) Px=pathologic change present, extract. RESULTS: A total of 92 patients with 227 pulpotomy-treated molars returned for at least 1 recall examination. Median follow-up for molars was 24 months (range=12-38 months). MTA molars demonstrated significantly fewer Px radiographic outcomes than FS molars (P=.002, chi-square test). Eugenol-free FS molars demonstrated significantly more Px radiographic outcomes than MTA (P<.001, chi-square test) or FS/MTA (P=.002, chi-square test) molars. Significantly lower survival was demonstrated for eugenol-free FS molars compared to MTA molars (P=.02, log-rank test) over 6 to 38 months. CONCLUSIONS: Outcomes for mineral trioxide aggregate pulpotomy were superior to ferric sulfate and eugenol-free ferric sulfate pulpotomy after a median follow-up of 2 years.

Variation in urban and rural water fluoride levels in Ontario.

OBJECTIVE: To compare levels of water fluoridation in urban and rural distribution systems in Ontario. METHODS: A random sample of 17 urban and 17 rural municipalities was taken from a list of 445 municipalities. The Ontario Ministry of the Environment (MOE) website was used to identify the water treatment plants that supply these municipalities, and water quality reports published by each of these distribution systems for 2007 were collected. For municipal distribution systems without published reports, staff were contacted directly. RESULTS: Far more urban distribution systems (82%) fluoridate their water compared with rural systems (18%). Most urban water suppliers (14 of 17) meet the 2000 MOE fluoride level standard of 0.5-0.8 mg/L, a range that includes the recently adopted Health Canada standard of 0.7 +/- 0.1 mg/L. Only 3 of 17 rural distributors artificially fluoridate their water and 11 of 16 supply suboptimal levels of fluoride. CONCLUSION: Most Ontarians who live in rural areas receive levels of fluoride that are outside MOE standards. Urban water distribution systems that regulate their fluoride content are compliant with the range recommended in 2000. The communal water supplies of some rural residents of southwestern Ontario contain levels of natural fluoride that are well above the standard for artificially fluoridated water.

Effects of severe dentoalveolar trauma on the quality-of-life of children and parents.

BACKGROUND/AIM: This investigation assessed the effects of dental trauma on the perception of pain and quality of life (QoL) of patient-parent pairs for a year following severe injuries. SAMPLE: A visual analogue scale (VAS) was used to assess the pain of injury and treatment for 27 individuals 8-20 years and their parents. The Child Oral Health Quality of Life (COHQoL) survey was used to assess the effects of dental injuries on the QoL of 23 children aged 8-14 and their parents. RESULTS: Mean VAS scores revealed that all patients and parents perceived the pain of initial injury to be significantly greater than pain of splint removal (P < or = 0.05) and that pain decreased in a stepwise manner from injury through emergency treatment to splint removal. The COHQoL questionnaire demonstrated a profound and continuing effect on children and their parent's QoL following severe dental injury. The initial parental COHQoL score was significantly greater than the 12-month score (P < or = 0.05) in both 8-10 and 11-14- year-olds. The COHQoL results indicated a measurable reduction in the QoL of patients and parents was still present 12-months after the injuries. At the end of one-year children were still affected by the social and well-being aspects of the injury yet parents exclusively reported that one-year effects were limited to their children's oral symptoms and functional limitations. CONCLUSIONS: Severe dental injuries produce initial and ongoing pain. Detrimental effects on the QoL of both children and parents are still present at one-year and these long-term effects are different for children and parents.

Does Emdogain work?

Emdogain has been available commercially for just over a decade. It is used currently in clinical practice of periodontics and has been investigated in four clinical outcome studies of replanted teeth. This review covers the origin and concepts behind the use of this amelogenin derivative, the unique conditions associated with an avulsed tooth, and the laboratory and clinical characteristics of this material. Emdogain continues to be an experimental material for replantation applications.

Spatial and temporal variability of ribotyping results at a small watershed in South Carolina.

The utility of library-based ribotyping methods for a very small study area was evaluated through comparison of local results to libraries with differing spatial and temporal scales. Ribotyping of Escherichia coli isolates was used to evaluate sources of fecal pollution at a coastal golf course in Beaufort County, South Carolina. Thirty-five E. coli isolates were obtained from water samples from a detention pond for testing against several local and regional libraries of known-source isolate patterns. A library of 92 E. coli ribotype patterns was created from wildlife feces obtained on the site. Additional libraries were available for comparison, including a library from Morgan Island, a small, geographically isolated area (including a monkey colony), and a library from ongoing statewide assessments. Seventeen (49%) of the unknown E. coli isolates matched isolates from raccoon and deer scat from the local library. Two isolates (6%) were matched with monkey sources from Morgan Island, and 13 (37%) were matched to raccoon, deer, and cows from the statewide assessment. Evaluation of repeated ribotyping analyses at the study area revealed evidence of temporal variability of potential sources in the local library. Only one of the isolates from the second year of fecal samples successfully matched with a fecal isolate from the previous year. The results from this study suggest that source identification results were variable both spatially and temporally, and that local, temporally specific libraries are most appropriate for library-based MST studies in small watersheds. Results also suggest that it will be difficult to employ adequate sample sizes to satisfactorily address unknown pattern variability.

Nontraumatic dental complaints in a pediatric emergency department.

OBJECTIVE: To determine the prevalence, types, and treatment of nontraumatic dental emergencies that present to a tertiary care pediatric emergency department (ED). METHODS: A retrospective chart review of all children coming to a tertiary care pediatric emergency department with nontraumatic dental complaints from January 2005 to December 2005 was conducted. Demographic information, the time and day of presentation, presenting complaints, history of previous dental treatment, interventions, and disposition details were collected and analyzed. RESULTS: The 247 visits for nontraumatic dental complaints comprise 0.5% of all patients who presented to the ED in 2005. Fifty-nine percent were younger than 5 years (primary dentition), with males representing 52% of the children. Half of the visits were during normal dental office hours, and more than half presented during the weekday. Fifty-three percent complained of pain. Twenty-eight percent were referred to the dental clinic after being seen by an ED physician. Eight percent of children required hospitalization for intravenous antibiotics. Most children (82%) were discharged from the ED with oral antibiotics. CONCLUSIONS: The ED is an important point of care for nontraumatic pediatric dental complaints, and about 60% of these children are younger than 5 years. Only 8% of them had severe infections requiring hospitalization, and most patients could have been treated in the community.

Characterization of root surface periodontal ligament following avulsion, severe intrusion or extraction: preliminary observations.

This study employed novel topographic and histological techniques to assess remaining periodontal ligament (PDL) in a convenience sample of avulsed and intruded human permanent incisors and extracted premolars. Seventeen human teeth (eight avulsed, five severely intruded and four uninjured extracted) were evaluated for the distribution and physical characteristics of adherent root surface PDL. The topographic distribution of PDL was assessed by staining roots with malachite green and determining the proportion of remaining PDL within selected regions on four aspects of each tooth. In order to characterize mechanical damage to PDL, serial transverse sections of roots were stained with hematoxylin and eosin and examined at magnifications of 40x to 800x. The sections were photographed and imaging software was used to calculate the percentage of remaining PDL in the circumference of each root section. Topographic analysis demonstrated that 54% of the PDL remained on roots of avulsed and severely intruded incisors and 36% of the PDL remained on the extracted single-rooted premolars. Examination of serial transverse root sections revealed that 58% of the PDL remained on roots of avulsed or severely intruded incisors and 54% on extracted premolars. Avulsed and severely intruded incisors demonstrated similar amounts of retained PDL. In both injuries, almost half of the root surface was denuded of PDL.

Etiology and environment of dental injuries in 12- to 14-year-old Ontario schoolchildren.

This study reports on the etiology and environment where dental injuries occurred and assesses the relationship between dental trauma, socio-economic status and dental caries experience. A population-based, matched case-comparison study was undertaken in 30 schools in two Ontario communities. Dental hygienists calibrated in the use of the Dental Trauma Index (DTI) screened 2422 children aged 12 and 14 years using DTI and Decayed, Missing and Filled Teeth indices. Cases (n = 135) were children with evidence of dental injury. Controls (n = 135) were children randomly selected after screening and matched with cases according to age and gender. Questionnaires were mailed to parents and children. Prevalence of dental injury was 11.4%, mostly minor injuries 63.7% (enamel fracture not involving dentin), affecting one upper central incisor (70.4%). The mean age at the time of dental injuries was 9.5 years (SD = 1.49; range: 6-13 years). Dental trauma most often occurred among boys at school because of falls or while playing sports. The relationship between dental injuries and the socio-economic indicators chosen was not statistically significant. However, a statistically significant direct relationship (P < 0.001) was shown between increased caries experience and dental injuries. This should focus attention on possible common-risk factors such as health-related behavioral problems that may affect both dental disease and dental injuries.

Impact of treated and untreated dental injuries on the quality of life of Ontario school children.

A population-based, matched case-comparison study was undertaken in 30 schools in two Ontario communities to measure the impact of dental trauma on quality of life (QoL) in Canadian school children. Dental hygienists screened 2422 children aged 12-14 years using the dental trauma index, the decayed, missing and filled teeth index (DMFT) and the aesthetic component of the index of orthodontic treatment needs (AC-IOTN). Cases (n = 135) were children with evidence of previous dental trauma. Controls (n = 135) were classmates matched for age and gender. Oral-health-related QoL was assessed using mailed Child Perception Questionnaires (CPQ(11-14)) completed by all children. Data were analyzed using simple and multiple conditional logistic regressions after adjusting for DMFT and AC-IOTN, CPQ(11-14), overall impact and item-specific impacts. Approximately 64% of injuries were untreated enamel fractures and just over 30% were previously injured restored teeth. Untreated children experienced more chewing difficulties (P = 0.026), avoided smiling (P = 0.029) and experienced affected social interactions (P = 0.032) compared with their non-injured peers. When treated and non-injured groups were compared, the only statistically significant effect was difficulty in chewing (P = 0.038). Injured children who were untreated experienced more social impact than their non-injured peers. Restoration of injured teeth improved aesthetics and social interactions but functional deficiencies persisted as a result of periodontal or pulpal pain.

Prioritization for elective dental treatment under general anesthesia.

This paper describes the process and outcomes of an initiative to develop a system to prioritize operating room bookings for children who require elective dental treatment. This initiative had 3 objectives: to improve the timeliness of treatment in the operating room based on medical and dental need, to provide a means to identify and expedite the highest-priority cases when operating room time became available, and to document the prioritization of cases as a quality assurance measure. Each patient booked for treatment in the operating room was assigned a priority ranking based on a combination of their medical risk and dental status. Measures of interrater reliability between clinician raters were moderate to good. Use of the prioritization system demonstrated improved timeliness of treatment for urgent cases and the effects of additional measures taken to reduce the waiting list.

Use of mouthguards among 12- to 14-year-old Ontario schoolchildren.

OBJECTIVES: To investigate the frequency of use of mouthguards among a representative sample of Ontario schoolchildren, the type of mouthguard most commonly used and reasons for noncompliance during sporting activities. MATERIALS AND METHODS: A population-based, matched case-control study was undertaken in a total of 30 schools in 2 suburban Ontario communities. Dental hygienists trained in the use of the Dental Trauma Index screened 2,422 children 12 to 14 years of age. Of 810 children identified as potential cases (with evidence of dental trauma) and controls (no dental trauma), 270 responded to a mail survey (135 cases and 135 age- and sex-matched controls). The children with dental injuries provided information such as the age at which the injury occurred and the setting and causes of the injury. Children from both case and control groups answered questions concerning use of mouthguards during sports. Parents provided demographic and other information. RESULTS: Only 5.5% of children wore mouthguards for school sports, and 20.2% wore protection in league sports. Of those who wore mouth protection, 48.2% wore boil-and-bite mouthguards and 21.4% wore stock-type mouthguards; only 30.4% wore professionally made, custom mouthguards. This high proportion of ill-fitting mouthguards was the major contributor to the commonly perceived problems of speech, breathing discomfort and poor appearance associated with mouthguard use. Boys were 1.52 times more likely to wear mouthguards than girls. Data on history of dental trauma and regularly visiting a dentist were not related to mouthguard use. The single most important predictor of mouthguard use was parents who had private dental insurance (p = 0.02), followed by having a family dentist (p = 0.16). CONCLUSION: Mouthguard use was very low in both school and league sports in this sample of Ontario schoolchildren, and the largest proportion of those who wore mouth protection used generic products rather than custom-fitted mouthguards. Lack of parental or coaching advice on mouthguard usage and peer beliefs about esthetics and function were the main reasons for noncompliance.

Guidelines for the Management of Traumatic Dental Injuries: 2. Avulsion of Permanent Teeth.

Avulsion of permanent teeth is one of the most serious dental injuries, and a prompt and correct emergency management is very important for the prognosis. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the task group. The guidelines represent the current best evidence and practice based on literature research and professionals' opinion. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion or majority decision of the task group. Finally, the IADT board members were giving their opinion and approval. The primary goal of these guidelines is to delineate an approach for the immediate orurgent care of avulsed permanent teeth.

Guidelines for the Management of Traumatic Dental Injuries: 1. Fractures and Luxations of Permanent Teeth.

Traumatic dental injuries (TDIs) of permanent teeth occur frequently in children and young adults. Crown fractures and luxations are the most commonly occurring of all dental injuries. Proper diagnosis, treatment planning and followup are important for improving a favorable outcome. Guidelines should assist dentists and patients in decision making and for providing the best care effectively and efficiently. The International Association of Dental Traumatology (IADT) has developed a consensus statement after a review of the dental literature and group discussions. Experienced researchers and clinicians from various specialties were included in the group. In cases where the data did not appear conclusive, recommendations were based on the consensus opinion of the IADT board members. The guidelines represent the best current evidence based on literature search and professional opinion. The primary goal of these guidelines is to delineate an approach for the immediate or urgent care of TDIs. In this first article, the IADT Guidelines for management of fractures and luxations of permanent teeth will be presented.