Paget's disease.

A review of the signs, symptoms, and treatment of Paget's disease is presented. Paget, or osteitis deformans, is a chronic, progressive, bone disease of viral etiology. Recent investigations about the causative agent of this disorder have implicated the measles virus of the paramyxovirus family. Additional studies have demonstrated that abnormal virus-infected osteoclasts generate interleukin (IL)-6, a resorptive cytokine from the bone marrow of patients with Paget's bone disease.

Diabetes mellitus and the dental pulp.

This study attempts to evaluate the oral manifestations of and the limited available dental pulp information on diabetes mellitus, a common metabolic disorder of carbohydrate and lipid metabolism affecting over 16 million Americans. Diabetics are particularly prone to bacterial or opportunistic infections. This vulnerability is caused by a generalized circulatory disorder whereby the blood vessels are damaged by the accumulation of atheromatous deposits in the tissues of the blood vessels lumen. In addition, blood vessels, particularly capillaries, develop a thickened basement membrane, which impairs a leukotactic response, and there is a decrease in the polymorphonuclear leucocyte microbicidal ability and failure to deliver the humoral and cellular components of the immune system. Because the dental pulp has limited or no collateral circulation, it is more prone to be at risk for infection. Clinical and radiographic studies by other investigators have shown that there is a greater prevalence of periapical lesions in diabetics than in nondiabetics. In a study of 252 diabetics with poor glycemic control, a high rate of asymptomatic tooth infection was found. Inflammatory reactions are greater in diabetic states, and the increased local inflammation causes an intensification of diabetes with a rise in blood glucose, placing the patient in an uncontrolled diabetic state. This often requires an increase in insulin dosage or therapeutic adjustment. Removal of the inflammatory state in the periodontium created a need for a lesser amount of insulin for glycemic control. Thus, it is essential to remove all infections including those of the dental pulp. When diabetes mellitus is under therapeutic control, periapical and other lesions heal as readily as in nondiabetics.

Pulpal pain diagnosis--a review.

Evidence gathered from our studies and the work of others appears to support the presence of two distinct nerve pain pathways in the dental pulp, represented by fast conducting A-delta and slow conducting C-fibers. Each of these types of fibers has different pain characteristics: A-delta fibers evoke a rapid, sharp, lancinating pain reaction, and C-fibers cause a slow, dull, crawling pain. Pain response thresholds vary in different regions of the tooth, and thermal, osmotic, ionic, and electric stimuli involve different mechanisms to provoke nerve excitation of the dental pulp. Evidence also points to the fact that the incidence of pain increases as the histopathosis worsens. On interrogation, patients who manifest severe or referred pain almost always give a previous history of pain in the tooth with the ache. Eighty percent of patients who give a previous history of pain manifest histopathologic evidence of chronic partial pulpitis with partial necrosis, the untreatable category, for which endodontics or extraction is indicated. The other 20% exhibit histopathosis of the pulp with slight inflammation to chronic partial pulpitis without necrosis, a treatable category. Clinically, one can determine the degree of pulp histopathosis by asking the patient about a previous history of pain in the involved tooth. This history of previous pain adds another dimension in diagnosis for the clinician as to whether the painful pulpitis is reversible. This information also aids in referred pain localization.

Reversible and irreversible painful pulpitides: diagnosis and treatment.

The foregoing clinical evidence indicates that when pain is severe, or when mild to moderate pain is present with a previous history of pain in the aching tooth, with or without periapical radiolucency, the tooth is in the IRPP category. Treatment dictates endodontic therapy or extraction. On the other hand, when clinical evidence indicates that the pain is mild or moderate with no previous history of pain, normal pulp vitality, and there is no positive percussion sign, the pulp is in the RPP category. Treatment dictates indirect or direct pulp capping in teeth with or without periapical radiolucency. The success rate favours teeth with no periapical radiolucency, 98%; in teeth with periapical radiolucency the success rate is less favorable, 43%. Efforts should be made to maintain pulp vitality. Endodontic therapy can always be done, if in time the pulp develops necrosis.

Periapical replacement resorption of permanent, vital, endodontically treated incisors after orthodontic movement: report of two cases.

Radiographic observations show that periapical replacement resorption (PARR) is a frequent and unpredictable sequella of orthodontic movement of permanent maxillary incisors. Only the apical root portion undergoes resorption, and it is subsequently replaced with normal bone. PARR also occurs without orthodontic tooth movement, but these resorptions differ as to type and location. PARR clearly occurs in teeth with vital pulps after orthodontic movement; however, our two cases and a review of 43 other cases indicate that endodontically treated incisors show a statistically significant lesser frequency and severity of apical resorption than untreated teeth. The role the vital pulp plays in this apical resorption is yet to be determined. A hypothetical explanation is offered suggesting that pulpal neuropeptides may be involved in PARR in both vital and endodontically treated incisors. The role calcium hydroxide plays in endodontically treated teeth is also considered.

Dental observations in Gaucher's disease: review of the literature and two case reports with 13- and 60-year follow-ups.

Gaucher's disease is a genetically determined inborn error of metabolism in which acid beta-glucosidase or one of its cofactors is absent or diminished in macrophage cells and cause an accumulation of glucosylceramide in these cells. These Gaucher cells accumulate in the organs of the reticuloendothelial system and cause varying degrees of splenomegaly, hepatomegaly, and encroachment of the marrow cavity of bones. Dental radiographs often reveal consistent bony changes that result from this encroachment. In cases where visceral signs are not apparent, dental radiographs can detect the presence of the disease. Because therapy is available, early recognition of this disorder may reduce overall morbidity. A review of the dental radiographic changes over as many as 60 years shows the effects of oral surgery procedures on bone degeneration and regeneration. The effects of mannose lectin acid beta-glucosidase, alglucerase on bone deposition are discussed. Finally, a literature review shows that the changes in the dental radiograph of patients with Gaucher's disease are very specific. Currently, this disorder and its associated molecular genetics are a prototype for research of new treatments such as allogenic bone marrow transplantation and molecularly engineered enzymes.

Intentional replantation of endodontically treated teeth.

This article reports 31 cases of intentional replantation with an overall success rate of 80.6% with six recorded failures. Survival times varied from 1 day to 22 years. A second mandibular molar that failed after 3 weeks was replanted successfully a second time with no signs of failure after a 46-month follow-up period. Two cases of intentional replantation of deciduous molars are also reported. We suggest that intentional replantation reduces adverse outcomes and should be considered as another treatment modality and not as a procedure of last resort. This procedure is recommended as the treatment of choice in the following instances: for lower second molars, for single-rooted teeth, and lower first molars when there is difficulty in accessibility to perform apical surgery; when the mental foramen is superimposed over the apex of the premolars; when the molar apex is in proximity to the mandibular canal; when patients object to periradicular surgery; when failures occur after apical surgery, or when surgery would create a periodontal pocket as a result of extensive bone removal. Periradicular surgery with a retroseal is more advantageous for first molars when roots are more curved, widespread, and are more prone to fracture compared with second molars whose roots are more tapered and close together.

Dental bacteremia and its relationship to bacterial endocarditis: preventive measures.

This article indicates that using local degerming agents in conjunction with traditional antibiotics prevents dental bacteremia more effectively than either procedure alone. In many patients at risk for endocarditis who practice home-care procedures than can produce bacteremia from gingival bleeding, daily antibiotic prophylaxis is impractical and contraindicated. This article discusses an effective method to control daily bacteremia with 0.2% chlorhexidine mouthwash. The article also attempts to identify patients at risk, determine the degree that they are exposed to potentially bacteremic situations, and encourage an aggressive team approach of physician and dentist to protect such patients adequately. Recommendations to prevent bacteremia are offered to supplement traditional antibiotic regimens.

The optimum placement-site of the electrode in electric pulp testing of the 12 anterior teeth.

The present study of 2,387 recordings of 12 anterior teeth in 53 patients indicates that the incisal edge is the optimal placement-site for the electric pulp tester to determine the lowest response threshold. The results show significant individual variations in the lowest threshold responses of the cervical-third, middle-third, incisal one-third, and incisal edge sites on a tooth, with a confidence level of 99%, according to the analysis of variance. The maxillary teeth gave a higher response threshold than the mandibular teeth and different types of teeth (canines and incisors) had statistically significant different response thresholds. The application of the electric pulp tester to the incisal-edge region with exposed dentin produced the most significant decrease in the threshold response.