The use of medicaments in the management of symptomatic irreversible pulpitis: A community-based cohort study.

AIM: To investigate patient outcomes from either pulpotomy or pulpectomy for the management of symptomatic irreversible pulpitis, with and without application of antibiotic/corticosteroid pastes in urgent primary dental care settings in the United Kingdom. METHODOLOGY: All patients receiving intervention for symptomatic irreversible pulpitis in three different primary care settings were invited to participate. Pre-operatively, data regarding patients' numerical ratings scale (NRS), pain score (0-10), analgesic use, oral-health impact profile-14 (OHIP-14) and need for time away from work were collected. For 7 days post-operatively, participants recorded their NRS pain score, global rating of change score, medication use and their ability to work. Analysis used a mixed-effects model with post hoc Tukey's multiple comparisons test for continuous data and chi-squared or Fisher's exact test for categorical data. To test the effect of the corticosteroid/antibiotic paste, pulpectomy and pulpotomy groups were combined following Mantel-Haenszel stratified analysis or a weighted average of the difference between pulpotomy and pulpectomy with and without the use of corticosteroid/antibiotic paste. A binary composite score was constructed using pre- and post-operative data, whereby overall treatment success was defined as: (i) patients did not return for treatment due to pain by day seven; (ii) at day three, there was a 33% (or 2-points) reduction in NRS pain score; (iii) there was a change score of +3 in global rating; (iv) the patient was no longer using analgesia and able to return to work. RESULTS: Eighty-five participants were recruited, with 83 completing follow up. Overall treatment success was 57%, with 25% of participants returning for more treatment due to inadequate pain relief. Overall treatment success did not differ between the two groups (p = .645), although patients self-reported greater improvement with an antibiotic/corticosteroid dressing for global rating of change (p = .015). CONCLUSIONS: This study identified limited evidence of improved outcomes using antibiotic/corticosteroid dressings in the management of symptomatic irreversible pulpitis in the emergency setting. Further clinical research is needed to understand if these medications are beneficial in affording pain relief, above that of simple excision of irreversibly inflamed pulp tissue.

The financial and quality of life impact of urgent dental presentations: A cross-sectional study.

AIM: This study aimed to: (i) calculate personal financial costs associated with urgent dental attendance; and (ii) investigate the pain-related disability and quality of life impact of dental conditions which result in urgent dental attendance. METHODOLOGY: Data were collected from those presenting with urgent dental conditions to an out-of-hours dental service, a dental emergency clinic (DEC) and five primary care general dental practices across North-East England. A pre-operative questionnaire explored the impact of urgent dental conditions on oral health-related quality of life (OHRQoL) using Oral Health Impact Profile-14 (OHIP-14) and a modified Graded Chronic Pain Scale (GCPS). OHIP-14 yields a maximum score of 56, with a higher score indicating a lower OHRQoL. Personal financial costs were summed to provide a total. These included travel, appointment fees, childcare costs, medication use and time away from work. Data were analysed using one-way anova and multivariable modelling. RESULTS: In total, 714 participants were recruited. The mean OHIP-14 score was 25.73; 95% CI [24.67, 26.79], GCPS CPI was 71.69; 95% CI [70.09, 73.28] and GCPS interference was 49.56; 95% CI [47.24, 51.87]. Symptomatic irreversible pulpitis was the most frequently managed dental emergency and was associated with the highest mean OHIP-14 score (31.67; 95% CI [30.20, 33.15]). The mean personal financial cost of urgent dental care (UDC) was £85.81; 95% CI [73.29, 98.33]. Differences in travel time (F[2, 691] = 10.24, p < .001), transport costs (F[2, 698] = 4.92, p = .004), and appointment time (F[2, 74] = 9.40, p < .001) were significant between patients attending an out-of-hours dental service, DEC and dental practices for emergency care, with a DEC being associated with the highest costs and dental practices the lowest. CONCLUSIONS: Diseases of the pulp and associated periapical disease were the most common reason for patients to present for UDC and were the most impactful in terms of OHRQoL and pain in the present sample. Personal financial costs are significant from urgent dental conditions, with centralized services increasing the burden to patients of attending appointments.

Dental antibiotics and referrals in general medical practice: Wales 1974-2017.

OBJECTIVES: This study aimed to explore trends and predictors for antibiotic prescriptions and referrals for patients seeking dental care at General Medical Practitioners (GMPs) over a 44-year period in Wales, UK. METHODS: This retrospective observational study analysed data from the nationwide Secure Anonymised Information Linkage Databank of visits to GMPs. Read codes associated with dental diagnoses were extracted from 1974-2017. Data were analysed using descriptive statistics, univariate and multivariable logistic regression. RESULTS: Over the 44-year period, there were a total of 160,952 antibiotic prescriptions and 2,947 referrals associated with a dental attendance. Antibiotic prescriptions were associated with living in the most deprived (OR 0.91, 95% CI 0.89-0.93) or rural (OR 0.83, 95% CI 0.82-0.84) areas, whereas referrals were associated with living in an urban area (OR 2.16, 95% CI 1.99-2.35) or rural and less deprived area (OR 1.71, 95% CI 1.26-2.33). The number of antibiotic prescriptions decreased over time whereas the number of referrals increased. CONCLUSIONS: These changes coincide with dental attendance rates at GMPs over the same period and indicate that appointment outcome and repeat patient attendance are linked. Rurality and deprivation may also influence care provided. CLINICAL SIGNIFICANCE: General medical practices are not the most appropriate place for patients seeking dental care to attend, and efforts should be made to change current practice and policy to support patients to seek care from dental practices. When patients do seek dental care from GMPs they should be encouraged to refer the patient to a dentist rather than prescribe antibiotics as an important element of national antimicrobial stewardship efforts, as well as to discourage repeat attendance.

How is carious pulp exposure and symptomatic irreversible pulpitis managed in UK primary dental care?

AIM: To investigate attitudes and approaches of UK primary care dentists to carrying out vital pulp treatment (VPT) after carious exposure and with additional signs and symptoms indicative of irreversible pulpitis. METHODOLOGY: An electronic questionnaire was openly distributed via publicly funded (NHS) local dental committees, corporate dental service-providers, professional societies and social media. Principally NHS practitioners and those from mixed and private practice were targeted, in addition to community and military dental officers, and dental therapists. Participants were asked questions relating to several clinical scenarios, with responses analysed using descriptive statistics. χ2 tests with sequential Bonferroni correction were used to explore variables including the method of remuneration, practitioner type (dentist/therapist), postgraduate qualification(s), place of graduation and years since qualification. Variables with a relationship p ≤ .2 were selected for backwards likelihood ratio logistic modelling. RESULTS: In total, 648 primary care practitioners were included for analysis. Calcium hydroxide (CH) was most frequently used for direct pulp caps (DPCs) (398/600; 66.3%) with calcium silicate cements (CSCs) less frequently used (119/600; 19.8%). Rubber dam was used by 222/599 (37.1%) practitioners. A definitive pulpotomy for the management of teeth with signs and symptoms indicative of irreversible pulpitis was selected by 65/613 (10.6%) dentists. The principal barrier for the provision of definitive pulpotomies was a lack of training (602/612; 98.4%). Regression analysis identified NHS practitioners as a good predictor for using CH for DPCs, having shorter emergency appointments, limited access to magnification and not using rubber dam. Non-UK graduates were more likely to select CSCs, appropriately control pulpal haemorrhage, undertake appropriate postoperative evaluation and use rubber dam. CONCLUSIONS: Practitioners deviated from evidence-based guidelines in a number of aspects including material selection, asepsis and case selection. A number of other challenges exist in primary care in providing predictable VPTs, including lack of time and access to magnification. These were most evident in NHS practice, potentially exacerbating existing social health inequalities. Possible inconsistencies in the UK undergraduate curriculum were supported by a lack of association between years since qualification and technique employed as well as the fact that non-UK graduates and dentists with postgraduate qualifications adhered more to evidence-based VPT guidelines.

Promoting regular dental attendance in problem-orientated dental attenders: A systematic review of potential interventions.

BACKGROUND: Problem-orientated dental attenders account for around one-third of the UK population, these being patients who do not seek regular dental care, instead only attending with dental pain. In order to develop intervention(s) to encourage regular dental attendance in these patients, any previous intervention development should be identified to aid idea generation or retrofitting of interventions. OBJECTIVE: To identify previous interventions which have been developed targeted at problem-orientated dental attenders to facilitate the development and co-design of a new intervention. METHODS: Eight electronic databases were searched for studies which included an intervention targeted at adult problem-orientated or irregular dental attenders to encourage regular dental attendance. Data on the intervention design mapped to the theoretical domains framework were extracted, alongside effectiveness and patient views where available. RESULTS: Three studies fitted the inclusion criteria for the review. Interventions identified were attendance at a dental anxiety clinic, and a large advertising campaign promoting a free dental update where members of the public could visit local dental practices to look around and meet the dentists. One study looked at the effect of policy change by introducing free dental check-ups in Scotland. Interventions were poorly reported, with significant omissions in their description and a lack of clear identification of what composed the intervention. CONCLUSION: There are very few interventions developed targeted at problem-orientated dental attendance, but important areas to consider in future intervention development include the following: dentist communication; dentist-patient relationship; increasing the awareness of need; the effect of free dental check-ups.

The effect of high-speed dental handpiece coolant delivery and design on aerosol and droplet production.

OBJECTIVES: High-speed dental instruments produce aerosol and droplets. The objective of this study was to evaluate aerosol and droplet production from a novel electric micromotor handpiece (without compressed air coolant) in real world clinical settings. METHODS: 10-minute upper incisor crown preparations were performed in triplicate in an open-plan clinic with mechanical ventilation providing 3.45 air changes per hour. A 1:5 ratio electric micromotor handpiece which allows water coolant without compressed air (Ti-Max Z95L, NSK) was used at three speeds: 60,000 (60 K), 120,000 (120 K), and 200,000 (200 K) revolutions per minute. Coolant solutions contained fluorescein sodium as a tracer (2.65 mmol L - 1). High-speed air-turbine positive control, and negative control conditions were conducted. Aerosol production was evaluated at 3 locations (0.5 m, 1.5 m, and 1.7 m) using: (1) an optical particle counter (OPC; 3016-IAQ, Lighthouse) to detect all aerosol; and (2) a liquid cyclone air sampler (BioSampler, SKC Ltd.) to detect aerosolised fluorescein, which was quantified by spectrofluorometric analysis. Settled droplets were detected by spectrofluorometric analysis of filter papers placed onto a rig across the open-plan clinic. RESULTS: Local (within treatment bay) settled droplet contamination was elevated above negative control for all conditions, with no difference between conditions. Settled droplet contamination was not detected above negative controls outside the treatment bay for any condition. Aerosol detection at 1.5 m and 1.7 m, was only increased for the air-turbine positive control condition. At 0.5 m, aerosol levels were highly elevated for the air-turbine, minimally elevated for 200 K and 120 K, and not elevated for 60 K. CONCLUSIONS: Electric micromotor handpieces which use water-jet coolant alone without compressed air produce localised (within treatment bay) droplet contamination, but are unlikely to produce aerosol contamination beyond the immediate treatment area (1.5 m), allowing them to be used safely in most open-plan clinic settings.

Exploring a temporal relationship between biofilm microbiota and inflammatory mediators during resolution of naturally occurring gingivitis.

BACKGROUND: This study uses multiple, contemporary methodologies to expand our knowledge of the temporal relationship between host-microbial interactions and clinical signs of gingivitis. METHODS: Subgingival plaque and crevicular fluid samples were collected from 31 systemically healthy adults with naturally occurring plaque-induced gingivitis. Professional prophylaxis was administered and participants were followed over 7 weeks. Microbial characterization was performed using a bead-based hybridization assay and cytokine analysis using bead-based flow cytometry. RESULTS: The provision of sequential interventions, oral hygiene instruction, and subsequent professional prophylaxis brought about significant reduction of plaque and resolution of gingivitis at all post baseline time points (P < 0.0001). Candidate cytokines that increased significantly (95% level) were interleukin (IL)-1ß, matrix metalloproteinases (MMP)-1, MMP-3, MMP-8, MMP-9, from baseline to week 2; regulated on activation, normal T cell expressed and secreted (RANTES) at week 4 and week 8; macrophage inflammatory protein (MIP)-1α and MIP-1ß at week 8. Resolution of inflammation was accompanied by a shift in the microbiological flora toward those species associated with health. CONCLUSIONS: This study provides further evidence of the dynamic relationships that exist between the overt clinical signs, the microbial biofilm, and the host response in gingivitis and upon resolution following clinical interventions. Understanding the interactions between the host immune system and subgingival microbial communities during the resolution of established gingivitis continues to evolve as additional knowledge is achieved through using new analytical technologies. The present study confirms a critical effect of oral hygiene measures on restoration of microbial eubiosis in subgingival communities, confirming the important role for home care and professional intervention in maintaining oral health.

Effect of topical neuromodulatory medications on oral and skin keratinocytes.

BACKGROUND: Neuromodulatory medications (NMs), such as amitriptyline, carbamazepine and gabapentin, are used as topical preparations for the management of neuropathic orofacial pain (NOP) and have produced promising preliminary results. The aim of this study was to investigate the effects of three aforementioned NMs on cell lines relevant to the orofacial tissues in vitro as no published studies have examined the effect of these topical NMs. METHODS: Cellular viability was measured using alamarBlue® , testing cumulative and specific time point effects of NMs on human skin keratinocytes and oral keratinocytes. Effects of the NMs on cell counts were investigated by CCK-8 assay. Drug concentrations released from NM orabase pastes after 30-min incubation were measured by high-performance liquid chromatography. Using these clinical concentrations, morphological changes and cytokine expression were investigated using scanning electron microscopy (SEM) and human inflammatory antibody array (AAH), respectively. RESULTS: Cumulative and specific time point viability and cell count methods revealed that amitriptyline caused a significant decrease in cellular viability and counts in both cell lines. Carbamazepine also had significant effects after long-term exposure and at higher concentrations, whilst gabapentin had little demonstrable effect. SEM confirmed the cytotoxicity of amitriptyline, whilst AAH revealed no significant changes in cytokine expression following amitriptyline, carbamazepine or gabapentin exposure compared with control. CONCLUSIONS: The results raise concerns about the safety of topical amitriptyline as it was cytotoxic to skin and oral keratinocytes in both exposure times and concentrations, whilst carbamazepine was cytotoxic only at high concentrations and after longer exposure times and gabapentin had no demonstrable effects.

The impact of structured plaque control for patients with gingival manifestations of oral lichen planus: a randomized controlled study.

AIM: To evaluate the impact of a structured plaque control intervention on clinical and patient-centred outcomes for patients with gingival manifestations of oral lichen planus. MATERIALS AND METHODS: Eighty-two patients were recruited into a 20-week randomized controlled trial. The intervention was structured plaque control comprising powered tooth brushing and inter-dental cleaning advice. Control subjects continued with their normal dental plaque control regimen. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. RESULTS: Overall, the intervention patients showed statistically significant improvements in OHIP sum ordinal and OHIP dichotomous scores compared with control. There were improvements in the functional limitation, psychological discomfort and physical disability domains at 4- and 20-weeks and in the psychological disability domain at 20-weeks. The intervention was successful in reducing plaque compared to control (p < 0.001) and improvements were observed using the mucosal disease indices at the 4- and 20-week follow-ups (p < 0.001). CONCLUSION: A structured plaque control intervention was effective in improving the oral health-related quality of life and clinically observed gingival lesions. This study provides evidence to include intensive plaque control within patients' initial and on-going management.

Cost-effectiveness of personalized plaque control for managing the gingival manifestations of oral lichen planus: a randomized controlled study.

AIM: To undertake cost-effectiveness and cost-benefit analyses of an intervention to improve oral health in patients presenting with the gingival manifestations of oral lichen planus (OLP). MATERIALS & METHODS: Eighty-two patients were recruited to a 20-week randomized controlled trial. The intervention was personalized plaque control comprising powered tooth brushing and inter-dental cleaning advice. The primary outcome measure was the oral health impact profile (OHIP) with secondary outcomes of pain, plaque index, mucosal disease score and cost-effectiveness. Private cost data and stated willingness-to-pay (WTP) values for treatment were obtained from intervention patients at 20 weeks. RESULTS: Overall, 81% of intervention patients showed improvement in both plaque index and mucosal disease score at 20 weeks compared to 30% of controls that continued with their usual plaque control regimen. All intervention group patients stated a positive WTP value. The mean net value of the treatment was £172 compared to the incremental cost of the treatment estimated at £122.75. The cost-effectiveness analysis resulted in an incremental cost-effectiveness ratio of £13 per OHIP point. CONCLUSIONS: The tailored plaque control programme was more effective than control in treating the gingival manifestations of oral lichen planus. The programme is cost effective for modest values placed on a point on the OHIP scale and patients generally valued the treatment in excess of the cost.