Endodontic implications of a patient with arteriovenous malformation: a case report and literature review.

AIM: To present the endodontic management of a patient diagnosed with a high-flow arteriovenous malformation (AVM) requiring root canal treatment and to discuss the relevant endodontic literature for this rare but significant problem. SUMMARY: AVM is a complex communication of an artery and a vein in which the oxygenated blood is forced away from the intended tissue. The incidence of its occurrence in the face and neck is rare, and when present, the most common sign is gingival bleeding. Arteriovenous malformation is both a diagnostic and therapeutic challenge for dentists. Also, there is ambiguity regarding the precautions to be taken whilst doing endodontic procedures in such cases. Hence, there is a need to understand the disease process and its implications in order to prevent life-threatening complications during treatment. This case report highlights the successful endodontic management of a cariously exposed right maxillary second premolar in a patient diagnosed with high-flow AVM. On an orthopantomogram, the AVM was spreading in the left submandibular space involving the left ramus area. The clinical findings of limited mouth opening with inter-appointment swelling and trismus during treatment made the case unusual and challenging. This paper addresses the current understanding of the classification, diagnosis, clinical features and endodontic management, together with specific guidelines and recommendations whilst performing endodontic procedures in AVM cases. KEY LEARNING POINTS: The classification and oral manifestations of AVM must be known and understood. Practitioners should be aware of the radiographic appearance of AVM. Recommended precautions should be taken when carrying out restorative and endodontic procedures in a patient with AVM. Antibiotic prophylaxis may be considered before endodontic treatment in a patient with AVM. Multidisciplinary treatment planning may be required.

Association between concentration of active MMP-9 in pulpal blood and pulpotomy outcome in permanent mature teeth with irreversible pulpitis - a preliminary study.

AIM: To investigate the correlation between the concentration of active-matrix metalloproteinases-9 (aMMP-9) in pulpal blood and the outcome of pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis (SIP). METHODOLOGY: Forty permanent molar teeth with a clinical diagnosis of SIP and normal apical tissues with periapical index (PAI) score ≤ 2 and ten permanent teeth (8 molars and two premolars) with a diagnosis of normal pulp that required root canal treatment for prosthetic reasons from patients between the ages of 15-35 years were recruited. All clinical procedures were performed under local anaesthesia and rubber dam isolation. After access opening, the coronal pulp tissue was amputated up to the canal orifice. A 100 µL volume of the pulpal blood was collected using a micropipette and transported to the laboratory. Sodium hypochlorite (2.5 %) was used as a haemostatic agent, and mineral trioxide aggregate (MTA) was used as the pulp capping material. The tooth was restored with composite at the same visit. Teeth with normal pulps were treated with single-visit root canal treatment. Patients with pulpotomy were recalled at 6 and 12 months. Outcome assessment of teeth with pulpotomy was carried out at 12 months and was categorized as success (asymptomatic patients with PAI score ≤ 2) or failure (symptomatic patients or PAI score ≥ 3). Quantification of aMMP-9 in pulpal blood was achieved using a fluorometric assay. The following statistical analyses were performed to assess the data: t-test, Fisher's exact test, kappa coefficient, non-parametric test, Wilcoxon rank-sum test, Spearman rank correlation test and receiver operating characteristic curve (ROC). RESULT: The success rate of pulpotomy was 88 % at 12-months. There was a significant difference between the median concentrations of aMMP-9 in pulpal blood of teeth with normal pulps (52 (12-96) ng mL-1 :) and SIP (193.3 (25.8-607.7) ng mL-1 :) (P = 0.0003) and successful (132.3 (25.8-548.3) ng mL-1 :) and failed cases (512.4 (334.8-607.7 ng mL-1 :) (P = 0.0015) of MTA pulpotomy. A significant association was established between aMMP-9 concentration and outcome of pulpotomy. The area under the receiver operating characteristics curve (0.9484, 95%CI) suggested excellent discriminatory power of aMMP-9 concentration in pulpal blood to predict the pulpotomy outcome. CONCLUSION: The pulpal blood concentration of aMMP-9 was significantly associated with the outcome of pulpotomy in teeth with symptomatic irreversible pulpitis, where it may be used as a potential prognostic biomarker.

Dentine sialoprotein expression in gingival crevicular fluid during trauma-induced root resorption.

AIM: To detect and quantify dentine sialoprotein (DSP) in the gingival crevicular fluid (GCF) of luxated teeth. METHODOLOGY: Eighteen subjects were enroled and distributed as follows. Group I (n = 6, positive control): subjects with primary second molar teeth undergoing physiological root resorption. Group II (n = 6, negative control): subjects with permanent mature maxillary central incisors. Subjects with a recent history (<1 week) of luxation injury were included in group III (n = 6, test group) and standardized digital radiographs with a superimposed mesh gauge were exposed at various time intervals. Percentage of radiographic root resorption (%RRR) was calculated. GCF was collected using microcapillary pipettes. DSP in the GCF was quantified using enzyme-linked immunosorbant assay. Group III was subjected to Spearman's rank test to establish the correlation between the concentration of DSP and %RRR at 6 weeks, 3 and 6 months. RESULTS: Quantifiable amounts of DSP were released in the GCF of subjects in Group I and III. However, the protein was not detected in Group II. Detectable quantities of DSP were observed in the GCF of luxated teeth before any radiographic evidence of root resorption (base line radiograph). A positive correlation was established at 6 weeks (r = 0.795), 3 (r = 0.755) and 6 month (r = 0.837) between the release of DSP and %RRR (P < 0.05). CONCLUSION: Dentine sialoprotein was released in the GCF of luxated teeth and its concentration correlated with the active and remission phases of this pathological process. Further investigation is required to establish a potentially noninvasive aid for diagnosing and monitoring root resorption.

Complicated crown fractures - management and treatment options.

AIM: Complicated crown fractures involve enamel, dentine and the pulp. The incidence of complicated crown fractures ranges from 2% to 13% of all dental injuries and the most commonly involved tooth is the maxillary central incisor. Various treatment modalities are available depending upon the clinical, physiological and radiographic status of the involved tooth. The aim of this article was to discuss techniques for the management of complicated crown fractures. SUMMARY: Management of complicated crown fractures depends upon several factors with the result that various clinical modalities have been suggested. Seven case reports of complicated crown fractures are presented and risks/benefits of the treatment plans are discussed. KEY LEARNING POINTS: Proper diagnosis, treatment planning and follow-up care are important factors in the prognosis of complicated crown fractures. Thorough understanding of the available treatment modalities and their specific indications is critical. The risks and benefits of each treatment option should be carefully evaluated during the treatment planning process.

True vertical tooth root fracture: Case report and review.

It is important for the clinician not only to gather as much information about a case as possible, but also to be able to correctly interpret the data to arrive at an accurate diagnosis. Occasionally, a case presents with symptoms that might be suggestive of a condition; however, the final diagnosis may be totally different. This paper reports on an interesting case of a true vertical root fracture, in an intact maxillary molar in a 55-year-old man. The case was misdiagnosed and treated as a periodontal defect for over two months. The paper discusses the various causes and diagnostic dilemmas of root fractures.

An ex vivo study to evaluate the remineralizing and antimicrobial efficacy of silver diamine fluoride and glass ionomer cement type VII for their proposed use as indirect pulp capping materials - Part I.

AIM: Indirect pulp capping (IPC) preserves the pulp vitality by disinfecting and remineralizing remaining carious dentin. In the present study, glass ionomer (GC, FUJI VII) and silver diamine fluoride (SDF) were tested and compared to calcium hydroxide for their antimicrobial efficacy and remineralizing potential. MATERIALS AND METHODS: Dentin disks prepared from 45 freshly extracted first premolars were divided into three groups (n = 15). Each disk was cut into two equal parts, in which one half formed the control. Thirty dentin samples were used for ion estimation and the other 15 for microhardness testing. Atomic absorption spectrophotometry, colorimetric and potentiometric titration analyses were performed for calcium, phosphate and fluoride ion detection, respectively. The antimicrobial efficacy was analyzed using pure culture of Streptococcus mutans and mixed flora. RESULTS: Increase in the levels of calcium and phosphate ions was the highest in calcium hydroxide group. Both SDF and GC VII groups showed significant increase in fluoride ion levels. Samples treated with GC VII showed maximum increase in micro hardness. The highest zone of bacterial inhibition was found with SDF group. CONCLUSIONS: This in vitro study documented the remineralizing, re-hardening and antimicrobial efficacy of both SDF and GC VII and hence can act as effective IPC materials.

Remineralizing efficacy of silver diamine fluoride and glass ionomer type VII for their proposed use as indirect pulp capping materials - Part II (A clinical study).

AIM: To evaluate in vivo the remineralizing efficacy of silver diamine fluoride (SDF), glass ionomer Type VII (GC VII) and calcium hydroxide (Dycal). MATERIALS AND METHODS: 60 subjects in the age group of 18-35 years, matching the inclusion criteria and having deep carious lesions in the permanent first and second molars were selected. The teeth were aseptically opened under rubber dam and after gross caries removal, approximately 0.4mg of soft discolored dentin was removed with a sharp spoon excavator from the mesial or distal aspect of the cavity. The test material was randomly selected and applied in a thickness of 1.5-2mm and the cavity sealed with cavit. The patients were followed up at regular intervals with radiographic evaluation at 12 weeks. At 3 months the temporary restoration was removed and dentin samples were collected from the other half of the cavity which was left in the first appointment. Atomic absorption spectrophotometry, Colorimetric test using UV-vis spectrometer and potentiometric titration were used for determining calcium, phosphorous and fluoride respectively. RESULTS: Almost equivalent rise in the percentage of calcium level was seen in GC VII and Ca(OH)(2) groups, followed by SDF group. Highest percentage rise in phosphate ions was seen in GC VII group followed by SDF group and Ca(OH)(2) group. Highest percentage of fluoride rise was seen in GC VII group followed by SDF group and Ca(OH)(2) group. CONCLUSIONS: The results indicated that both GC VII and SDF can be potential indirect pulp capping materials.