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.

Type-1 Dentine Dysplasia ­ Diagnostic and Clinical Challenges in Restorative Management.

Type-1 dentine dysplasia is a rare hereditary condition, associated with an abnormality in dentine formation. Deceptively, teeth have the clinical appearance of normality, however, radiographically, a different picture is seen; with multiple periapical radiolucencies associated with non-carious, unrestored teeth. This article reports the diagnostic and management challenges associated with dentine dysplasia in adults. Clinical relevance: Early diagnosis and preventive advice within primary care are imperative in the long-term outcomes.

The Paradoxes of Phantom Bite Syndrome or Occlusal Dysaesthesia ('Dysesthesia').

Phantom bite syndrome was first described by Marbach over 40 years ago as a mono-symptomatic hypochondriacal psychosis. He used the term to describe a prolonged syndrome in which patients report that their 'bite is wrong' or that 'their dental occlusion is abnormal' with this causing them great difficulties. This strong belief about 'their bite' being the source of their problems leads to them demanding, and subsequently getting, various types of dentistry carried out by multiple dentists and 'specialists'. Sadly, even after exhaustive, painstaking, careful treatment, none of the dental treatments manages to solve their perceived 'bite problems'. This is because they suffer from a psychiatric illness involving a delusion into which they continue to lack insight, in spite of the failures of often sophisticated dental treatments.1,2,3 In summary, dental practitioners, or other specialists, who suspect that they might be dealing with such a problem should refer these patients early on for specialist management by an appropriate specialist within the secondary care settings, preferably before they get trapped into the time-consuming quagmire of their management. A 'Phantom Bite Questionnaire', which is available to download free, might help. Clinical relevance: This article aims to provide professionals in various fields with guidelines on detecting, diagnosing and managing patients with Phantom Bite Syndrome (PBS). This is desirable in order to prevent extensive, or unnecessarily destructive, or unstable dental treatment being undertaken on such patients in a vain attempt to solve their problems with 'dentistry' when, in fact, these are really due to underlying mental health issues.

Smartphones and dental trauma: the current availability of apps for managing traumatic dental injuries.

BACKGROUND/AIM: There is a general consensus regarding the lack of awareness regarding the emergency management of traumatic dental injuries amongst laypersons and dental professionals. This article aims to provide an overview of the apps available for traumatic dental injuries using smartphones. These apps may serve as a gateway for raising awareness of traumatic dental injuries. MATERIALS AND METHOD: Three smartphone devices were used to access their respective app stores (Nokia Lumia 635 with Windows Phone OS 8.1; iPhone 5 with iOS 8.1; Samsung Galaxy Ace II with Android OS v2.3.6 Gingerbread). Nine phrases were searched: broken tooth/teeth; chipped tooth/teeth; dental emergency; dental injury; dental trauma; fractured tooth/teeth; knocked-out tooth/teeth; tooth/teeth injury; and tooth/teeth trauma. RESULTS: Seven apps for the Android and one app for the Apple operating system were relevant. The only Apple iOS app retrieved (Dental Trauma) was also found for the Android OS (Dental Trauma First Aid) and had the endorsement of the International Association of Dental Traumatology. AcciDent was the only app dedicated to traumatic dental injuries targeted solely towards dental professionals. Five other apps (Chipped Tooth Solution, Dental Crown Repair, Fixing Cracked Tooth, Repairing the Front Tooth and Solution to Broken Tooth) appeared to come from the same source (KBES). No traumatic dental injury apps were found for the Windows Phone OS. CONCLUSION: There are apps available for both patients and dentists that range in quality and on the whole lack real-life photographs. Future apps should continue to provide good quality, evidence-based and validated material.

Dental Attendance and Self-reported Oral Health Status of Renal Dialysis Patients: A Comparison of Results with the UK Adult Dental Health Survey.

PURPOSE: To compare the oral health status of renal patients attending a dialysis unit at a London teaching hospital with an age- and sex-matched sample from the Adult Dental Health Survey UK (ADHS) 2009. MATERIALS AND METHODS: Questions adapted from the ADHS 2009 national survey were used to interview renal dialysis patients about their oral health, oral hygiene and dental visits. Any significant differences between the two groups were statistically analysed using the chi-squared (χ2) test. RESULTS: Two hundred renal dialysis patients participated. More renal dialysis patients were edentulous (p < 0.0001) and those who were dentate had fewer teeth (p < 0.0001) compared to the ADHS 2009 participants. Although 12% of the renal dialysis patients had difficulty in finding a dentist, 77% were linked to a dental practice, but fewer reported that they had previously been shown how to brush their teeth compared to the dentate ADHS group (p < 0.0001). The frequency of brushing (twice daily) was similar in the dialysis and ADHS groups. CONCLUSION: Awareness for good oral health needs to be raised in this group of medically compromised patients regularly attending a hospital unit. The responsibility for achieving this goal needs to be shared by both dialysis teams and oral health care professionals. We suggest an 'oral health toolkit' be made available in dialysis units for both professionals and patients.

Dental Trauma Part 1- Acute Management of Luxation/Displacement Injuries.

Fortunately, traumatic dental injuries are a relatively uncommon occurrence in general dental practice. However, when they do present, timely diagnosis and treatment of such injuries is essential to maximize the chance of a successful outcome. This is the first part of a two-part series on traumatic dental injuries that are commonly encountered in the clinical setting. Part one will cover acute management of luxation/displacement injuries that primarily affect the supporting structures of the tooth, while part two will cover the management of fracture injuries associated with teeth and the alveolar bone. Clinical relevance: A simple, step-by-step approach in the diagnosis and clinical management of acute luxation/displacement injuries should be part of a dental clinician's knowledge.

Dental Trauma 2- Acute Management of Fracture Injuries.

Fortunately, traumatic dental injuries are a relatively uncommon occurrence in general dental practice. However, when they do present, timely diagnosis and treatment of such injuries is essential to maximize the chance of a successful outcome. This is the second part of a two-part series on traumatic dental injuries that are commonly encountered in the clinical setting. Part one covered the management of acute luxation/displacement injuries affecting the supporting structures of the tooth, while part two will cover the management of fracture injuries associated with teeth and the alveolar bone. Clinical relevance: Traumatic dental injuries are uncommon occurrences in everyday general dental practice. This article aims to provide a simple, step-by-step approach in the diagnosis and clinical management of acute fracture injuries.

What do dental students know about trauma?

AIM: To assess the baseline knowledge, knowledge acquisition and retention of dental undergraduate students in dental trauma, and the impact of a lecture on their level of confidence in managing traumatic dental injuries. MATERIAL AND METHODS: A total of 145 dental undergraduate students from King's College London were invited to attend a lecture on dental trauma. The participants were asked to complete a questionnaire on dental trauma before (T0), immediately after (T1) and 6 months (T2) following a 1-h lecture. RESULTS: Seventy of the 145 students participated in the study. The level of knowledge at T0, T1 and T2 was 64.9%, 83.2% and 69.5%, respectively. The increase in score was statistically significant between T0 and T1, and between T0 and T2. A significant decrease in score was also found between T1 and T2. Sex, level of education and whether or not the participants received previous teaching in dental trauma were not significant in predicting a change in score. The level of confidence increased significantly from 2.14 at T0 to 3.13 at T2. Participants who received teaching in dental trauma previous to the lecture were significantly more confident at T0. CONCLUSIONS: Lectures are effective at improving the knowledge and retention of knowledge of dental undergraduate students in dental trauma. However, retention of the knowledge is time limited suggesting that education should be repeated after a certain period of time to ensure that a high level of knowledge is maintained.

Challenges in treating traumatically intruded and ankylosed permanent incisors: a case report with a multidisciplinary approach.

This report discusses the challenges, complications and management of traumatic intrusion injuries affecting the permanent dentition. A case is described where trimming of the incisal edge of a severely intruded and ankylosed upper lateral incisor resulted in an unexpected re-eruption of the tooth. It is suggested that the vibrations from drilling may have disrupted the ankylosis, initiating spontaneous re-eruption and this approach could provide a minimally invasive and conservative pathway to treating ankylosed teeth. Clinical Relevance: To date no effective treatment has been described to reverse the development of replacement root resorption leading to the loss of the affected tooth. The hypothesis proposed here suggests that mechanical vibrations, if strong enough, may disturb the ankylosis and allow re-eruption of the intruded tooth.

The value of cone beam CT in assessing and managing a dilated odontome of a maxillary canine.

A case of an unusual anomaly in a maxillary canine is described. A deep enamel invagination resulted in pulpal necrosis, longstanding infection and development of an associated radicular cyst. Diagnostic X-ray imaging was invaluable in demonstrating the complex root anatomy of the dilated odontome. In particular, a cone beam CT scan helped in the formulation of an appropriate treatment plan. Clinical Relevance: Three-dimensional imaging using cone beam CT was valuable in this case to demonstrate the complicated anatomy of a rare dental anomaly, and to help plan treatment.

Decision-making in the provision of extra-coronal restorations.

UNLABELLED: Decision-making when choosing an extra-coronal restoration for a molar tooth is often multifactorial, requiring consideration for material properties, the underlying tooth tissue, aesthetics and functional requirements. This article reviews the various factors associated with the decision-making when considering an extra-coronal restoration for a molar tooth. The current literature is disseminated and compared to results obtained from clinicians at the Dental Pan Society meeting in 2007. Dentists were seemingly less likely to consider restorations with greater complications for themselves than they were for their patients. The various implications of the results are discussed. CLINICAL RELEVANCE: With the plethora of dental materials available, the clinician has a wide choice of restorations. As clinicians become increasingly aware of the relative complications associated with different restorations, they are less likely to choose those that may result in problems, such as loss of vitality. In comparison, patients, if not kept fully informed, are unlikely to be aware of these problems and therefore may be happy to accept a more 'aesthetic' restoration. This decision dynamic-is examined in this article.

Avulsion Injuries: Assessment and Management.

Avulsion injuries, though relatively uncommon, are one of the most serious of dentoalveolar injuries. Replantation at the scene of the incident is almost always the treatment of choice whenever possible. This paper outlines a step-by-step approach for the management of avulsion injuries, including a splinting protocol. This aims to support general dental practitioners in feeling more confident with managing these injuries.

Survival of immediate implants replacing traumatised teeth in the anterior maxilla.

Aim The provision of implants following traumatic dental injuries can hold many challenges, primarily in higher aesthetic regions. The purpose of this retrospective study was to assess the clinical outcomes of immediate implants placed in fresh extraction sites in the anterior maxilla following dental trauma.Materials and methods In total, 60 patients requiring teeth replacement with dental implants in the anterior maxilla were included in the study. Following a delayed loading protocol, the implants were restored with definitive single crowns or bridges. Implant and prosthetic survival, complications and periodontal health were recorded during follow-up.Results A total of 70 implants were placed in the anterior maxilla with three failures reported, resulting in an implant survival rate of 95.7% over a follow-up period of three years. No additional bone augmentation was undertaken and prosthetic survival recorded was 100%, with favourable periodontal outcomes achieved overall.Conclusion This study showed that implants immediately inserted into fresh extraction sites following dental trauma can constitute a predictable treatment strategy, presenting high implant survival rates over the follow-up period observed. Further well-designed controlled clinical trials are required to evaluate longer-term outcomes for this technique.

Contemporary management of tooth replacement in the traumatized dentition.

Dental trauma can result in tooth loss despite best efforts at retaining and maintaining compromised teeth (Dent Traumatol, 24, 2008, 379). Upper anterior teeth are more likely to suffer from trauma, and their loss can result in significant aesthetic and functional problems that can be difficult to manage (Endod Dent Traumatol, 9, 1993, 61; Int Dent J 59, 2009, 127). Indeed, teeth of poor prognosis may not only present with compromised structure but trauma may also result in damage to the support tissues. Injury to the periodontium and alveolus can have repercussions on subsequent restorative procedures (Fig. 19). Where teeth are identified as having a hopeless prognosis either soon after the incident or at delayed presentation; planning for eventual tooth loss and replacement can begin at the early stages. With advances in both adhesive and osseointegration technologies, there are now a variety of options for the restoration of edentate spaces subsequent to dental trauma. This review aims to identify key challenges in the provision of tooth replacement in the traumatized dentition and outline contemporary methods in treatment delivery.

Ethical marketing in 'aesthetic' ('esthetic') or 'cosmetic dentistry' part 2.

UNLABELLED: This is the second article in a series of three. It is essential to find out from patients what it is that they hope to achieve when requesting an improvement in their dental appearance. Their expectations, hopes and fears need to be explored in detail. The long-term biologic costs of some invasive procedures need to be explained to patients in advance so that they can make properly informed decisions. Failure to do so renders the practitioner vulnerable to a charge of behaving unethically. The differences between ethical marketing and selling are explained including the historic development of marketing. CLINICAL RELEVANCE: A practical approach, using a modification of the Edward de Bono Six Thinking Hats model is described to help ethical practitioners to develop sound treatment plans when dealing with complex aesthetic problems.

Ethical marketing in 'aesthetic' ('esthetic') or'cosmetic dentistry'. Part 3.

UNLABELLED: This, the third and final article in this series on ethical marketing, makes it clear that cosmetic dentistry is not a guaranteed one-way ticket to happiness for either patients or dentists, but it can be for lawyers. In fact, this area of dentistry is fraught with many dangers for the unwary patient and even for the enthusiastic or experienced dentist. In general, it is not at all wise to raise patient expectations beyond that which is definitely going to be easily achievable in his/her particular case. CLINICAL RELEVANCE: If things go wrong with extensive cosmetic dentistry, or are judged as being suboptimal, or unacceptable, by the patient, then that dentist may become liable for all the remakes of that elective cosmetic dentistry for the lifetime of the patient, together with all the associated general and specific damages. This is because, if the elective cosmetic dentistry had not been done, the patient would not have needed to have the remakes. Informed consent is a major issue with cosmetic dentistry, as is avoiding any possible claims for breach of contract, which could be verbal, implied or written.

Ethical marketing in'aesthetic' ('esthetic') or'cosmetic dentistry'. Part 1.

UNLABELLED: Prior to undertaking any elective,'cosmetic' dental procedures, it is vital for the treating dentist to discuss the merits and drawbacks of all viable options. It is important that the patient understands what the consequences and limitations of treatment are likely to be, and what the potential failures could entail later in his/her life. Informed consent should be obtained (preferably in writing) and the clinical notes and records should be clearly documented, with accurate and concise details provided of all the investigations carried out, and their findings, as well as including details of the various discussions that have taken place. Dentists need to be aware of the existence of heightened expectations in this group of patients and be cautious about accepting patients who have unrealistic 'cosmetic' expectations. Where possible, cosmetic or aesthetic dental treatment should be provided which is minimally destructive and, in the long-term, be in the 'best interests' of the patient. Important matters such as the gaining of informed consent and maintaining meticulous, contemporaneous dental records will also be emphasized. It is hoped that the article will provide clear definitions of some commonly used terms such as 'ethical marketing', 'ethics', and 'values', which are often used in association with the marketing, planning and undertaking of supposedly 'cosmetic' dental procedures. The important role of less invasive alternative treatment options will also be emphasized. CLINICAL RELEVANCE: The aims of this article are to consider the common pitfalls that may arise when contemplating the marketing and provision of invasive,'cosmetic, dental restorations and to discuss how best to avoid a dento-legal claim where such treatment plans may not fulfil the patient's desired outcome.

Management of acute traumatic dental injuries in the orthodontic patient.

Knowledge of managing traumatic dental injuries (TDIs) is imperative for all dental practitioners. With the number of adults undertaking orthodontic treatment increasing, and children and adolescents alike continually being treated for orthodontics under the NHS in the UK, it is imperative that all clinicians - specialists and generalists - are aware of how to manage the orthodontic appliance in a patient presenting with a TDI in their active phase of orthodontics.This guidance will aid practitioners in implementing pragmatic approaches to manage the orthodontic appliance in a patient presenting with a TDI. Key focus will be given on fixed appliance therapy. Case examples and flow diagrams outlining best practice are given to manage the TDI and orthodontic appliance concurrently.

Traumatic dental injuries in adults attending a London-based trauma clinic in the UK: a seven-year survey.

Introduction This survey reports the incidence of traumatic dental injuries in an adult population attending an adult dental trauma clinic in a London teaching hospital.Materials and methods Retrospective data were collected from patients attending an adult dental trauma clinic between 2012 and 2018.Results In total, 1,769 patients attended, with more men seen (1,030; 58.2%) compared to women (739; 41.8%) and this was statistically significant (p <0.05). The most common aetiological factor was an accidental fall (728; 41.15%), followed by assaults (413; 23.35%), bicycle accidents (253; 14.3%), sports injuries (132; 7.46%) and road traffic accidents (84; 4.75%). Lateral luxation (833) was the most common traumatic injury and this was followed by avulsions (362; 17%). Enamel-dentine fractures were the most common type of fracture injury (1,273; 64%).Discussion This retrospective survey attempts to report on the incidence of traumatic dental injuries in a London-based cohort of patients attending a specialised dental trauma clinic. In line with other reports, there were more men than women affected, which is probably attributed to behavioural activities.Conclusion(s) Accidental falls are the most common cause of a traumatic dental injury, lateral luxation was the most common type of displacement injury and enamel-dentine fractures were the most common type of fracture injury.

Multiple supernumerary teeth without any associated systemic condition or syndrome: a case report.

UNLABELLED: A 49-year-old Black African male, originally of Nigerian origin, was referred by his dentist regarding a bad taste in the mouth. He was seen in a general restorative clinic at Barts and the London NHS Trust. Clinical examination did not reveal any relevant abnormalities. A panoramic tomography, however, showed the presence of multiple supernumerary teeth, which were located in the maxillary right and left premolar and molar regions, and the mandibular left premolar region. The family's history was non-contributory. The patient was unaware of the supernumerary teeth and, as far as he knew, there were no other members of his family with a similar problem. CLINICAL RELEVANCE: A decision regarding the appropriate management of supernumerary teeth should be considered carefully since surgical removal of the teeth may cause damage to adjacent structures, including bone. In this respect, it is interesting and rare to find multiple supernumerary teeth in individuals with no other associated diseases or syndromes elucidated by clinical and historical enquiry.