Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions.

UNLABELLED: As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients. CLINICAL RELEVANCE: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Minimal intervention dentistry and older patients. Part 1: Risk assessment and caries prevention.

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.

The cost-effectiveness of supportive periodontal care: a global perspective.

AIM: To evaluate the cost-effectiveness of supportive periodontal care (SPC) provided in generalist and periodontal specialist practices under publicly subsidized or private dental care. MATERIAL AND METHODS: SPC cost data and the costs of replacing teeth were synthesized with estimates of the effectiveness of SPC in preventing attachment and tooth loss and adjusted for differences in clinician's time. Incremental cost-effectiveness ratios were calculated for both outcomes assuming a time horizon of 30 years. RESULTS: SPC in specialist periodontal practice provides improved outcomes but at higher costs than SPC provided by publicly subsidized or private systems. SPC in specialist periodontal practice is usually more cost-effective than in private dental practice. For private dental practices in Spain, United Kingdom and Australia, specialist SPC is cost-effective at modest values of attachment loss averted. Variation in the threshold arises primarily from clinician's time. CONCLUSION: SPC in specialist periodontal practice represents good value for money for patients (publicly subsidized or private) in the United Kingdom and Australia and in Spain if they place relatively modest values on avoiding attachment loss. For patients in Ireland, Germany, Japan and the United State, a higher valuation on avoiding attachment loss is needed to justify SPC in private or specialist practices.

Oxidative and inflammatory status in Type 2 diabetes patients with periodontitis.

AIM: To determine the impact of periodontitis on oxidative/inflammatory status and diabetes control in Type 2 diabetes. MATERIALS AND METHODS: A comparative study of 20 Type 2 diabetes patients with periodontitis [body mass index (BMI) 31+5], 20-age/gender-matched, non-periodontitis Type 2 diabetes controls (BMI 29+6) and 20 non-diabetes periodontitis controls (BMI 25+4) had periodontal examinations and fasting blood samples collected. Oxidative stress was determined by plasma small molecule antioxidant capacity (pSMAC) and protein carbonyl levels; inflammatory status by total/differential leucocytes, fibrinogen and high sensitivity C-reactive protein (hsCRP); diabetes status by fasting glucose, HbA1c, lipid profile, insulin resistance and secretion. Statistical analysis was performed using SPSS. RESULTS: pSMAC was lower (p=0.03) and protein carbonyls higher (p=0.007) in Type 2 diabetes patients with periodontitis compared with those without periodontitis. Periodontitis was associated with significantly higher HbA1c (p=0.002) and fasting glucose levels (p=0.04) and with lower ß-cell function (HOMA-ß; p=0.01) in diabetes patients. Periodontitis had little effect on inflammatory markers or lipid profiles, but Type 2 diabetes patients with periodontitis had higher levels of hsCRP than those without diabetes (p=0.004) and the lowest levels of HDL-cholesterol of all groups. CONCLUSION: Periodontitis is associated with increased oxidative stress and compromised glycaemic control in Type 2 diabetes patients.

Gerodontology--how big is the challenge in Ireland?

Population trends suggest that the Irish population is ageing, and that this population will have substantial treatment needs. These patients will be better informed than previous generations, and will demand treatment aimed at preserving a natural dentition. This will impact upon delivery of oral healthcare and manpower planning needs to consider how to address the increased demand for dental care. Poor oral health is associated with systemic health problems, including cardiovascular disease, respiratory disease and diabetes mellitus. It also has a negative impact upon quality of life, and the World Health Organisation has encouraged public healthcare administrators and decision makers to design effective and affordable strategies for better oral health and quality of life of older adults, which, in turn, are integrated into general health management programmes. Treatment concepts such as minimally invasive dentistry and the shortened dental arch concept are discussed in the context of these demographic changes and recommendations.

Periodontics: 9. Periodontitis and systemic conditions--is there a link?

UNLABELLED: The possibility that periodontal diseases have an effect on systemic health is being widely investigated. This paper reviews the potential links and the mechanism of these effects. CLINICAL RELEVANCE: Although the effects of periodontitis on systemic health do not yet have an effect on clinical decisions, knowledge and understanding of the link, effects and mechanism are important.

Periodontics: 8. Periodontal problems associated with compromised anterior teeth.

UNLABELLED: Periodontal disease can significantly impact on the appearance of the anterior teeth. Prior to any definitive treatment, stabilization of the periodontal condition is a requirement. Treatment options can range from the placement of simple restorations, through orthodontic realignment, to the extraction and replacement of hopeless teeth. Each treatment plan must be individually tailored to the patient and level of periodontal disease, and must include provision for maintenance periodontal therapy. CLINICAL RELEVANCE: Periodontal diseases may compromise the prognosis of anterior teeth. Management is challenging and clinicians should take into consideration the short and long-term survival in treatment planning.

Periodontics: 10. Maintenance in periodontal therapy.

UNLABELLED: Maintenance periodontal therapy is essential for the long-term stabilization of periodontal disease. An individualized programme of maintenance requirements, based on patient risk assessment for disease progression, is important, as is the need for teamwork in long-term patient management. CLINICAL RELEVANCE: Maintenance or supportive therapy is an essential requirement in the management of periodontal therapy. Patients should be informed at their first visit that part of the management of their disease is regular maintenance visits.

Periodontics: 5. Surgical crown lengthening.

UNLABELLED: The surgical crown lengthening procedures are usually used to facilitate the restoration of teeth with poor retentive properties. These techniques can also be applied to the management of aesthetic gingival problems. CLINICAL RELEVANCE: It is important that the need for crown lengthening procedures is evaluated before any complex restorative treatments are carried out.

Periodontics: 4. Surgical management of gingival and periodontal diseases.

UNLABELLED: Non-surgical periodontal therapy is the first line of management in the treatment of periodontitis. Gingival and periodontal surgery should be carried out after non-surgical therapy and on patients who show excellent plaque control. This article presents the indication, contra-indication and complications of gingival and periodontal surgery and the clinical outcome of the most common procedures used. CLINICAL RELEVANCE: Knowledge of the periodontal surgical procedures, their indication and outcomes, are important to allow adequate evaluation and referral.

Periodontics: 7. Periodontal problems associated with compromised posterior teeth.

UNLABELLED: Periodontitis affecting multi-rooted teeth presents a challenge for non-surgical and surgical management. This paper reviews the management of compromised posterior teeth. CLINICAL RELEVANCE: Successful management of compromised posterior teeth requires careful assessment of all contributing factors and the implementation of a long term maintenance programme.

Periodontics: 3. Non-surgical periodontal therapy in general dental practice.

UNLABELLED: Non-surgical periodontal therapy is an integral part of periodontal treatment and has been defined as plaque removal, plaque control, supra- and subgingival scaling, root surface debridement, and the adjunctive use of chemical agents. CLINICAL RELEVANCE: Knowledge of the role of non-surgical periodontal therapy is central to good patient care.

Periodontics: 6. The management of gingival recession.

UNLABELLED: Gingival recession is a common condition affecting the dentition. This paper describes the aetiology of gingival recession and discusses the appropriate management of this condition. CLINICAL RELEVANCE: Careful examination to detect gingival recession, or the factors that may place the patient at risk for recession, are important for prevention.

Periodontics: 2. Risk factors and susceptibility in periodontitis.

UNLABELLED: Periodontitis is an inflammatory condition initiated by microbial plaque but influenced by an array of factors that affect the development and progression of the disease. This paper summarizes the major risk factors for periodontal disease and the potential to modify specific factors. CLINICAL RELEVANCE: The assessment of patients with periodontal diseases must include an evaluation of risk and susceptibility. While removal of bacterial plaque and plaque-retentive factors remains the focus of treatment, for successful, long-term management of periodontal diseases, it is also important to eliminate known risk factors.

Periodontics: 1. Identification and diagnosis of periodontal diseases in general dental practice.

UNLABELLED: The diagnosis and management of periodontal diseases requires a detailed examination of the signs and symptoms associated with periodontal disease. This requires a screening procedure, the BPE being sufficient in the majority of cases. Detailed examination is, however, required in more advanced or severe cases. The general dental practitioner should follow a systematic and organized examination to identify and differentiate between individuals with gingivitis, and those with mild, moderate and more advanced forms of periodontitis. Treatment planning, including the decision to refer to a consultant/specialist when appropriate, requires a clear understanding and satisfactory interpretation of the information gathered from the examination. This reduces the risk of over or under treatment, helps in evaluating the individual's response to therapy and reduces the risk of litigation. CLINICAL RELEVANCE: The assessment and clinical examination of patients with periodontal diseases, as detailed in this paper, are essential for the diagnosis, effective treatment planning and future maintenance care of patients in general dental practice.

Attitudes to conscious sedation in patients attending an emergency dental clinic.

INTRODUCTION: Anxiety and fear in relation to dentistry are long-standing problems and the incidence of dental fear does not appear to be decreasing. It can result in poor dental health and wastage of clinical time. Conscious sedation is one method of allaying anxiety in dental patients and enables such patients to accept dental treatment. AIMS, MATERIALS AND METHODS: A questionnaire survey was undertaken among patients attending an emergency dental clinic. Its aims were to assess the levels of dental anxiety in these subjects, the impact on their attendance for dental treatment, and their knowledge of and desire to have conscious sedation, should it be available. RESULTS: The results indicated that in the 72 patients who responded, levels of anxiety regarding dental treatment were high, with 49 (68%) claiming some nervousness or worse. Thirty-one (43%) cited fear/nervousness as a reason for delaying making a dental appointment. Twenty-seven (38%) were not aware of the existence of conscious sedation for dental treatment, of whom half reported that they were in the highly anxious group. Forty (56%) respondents said they would like to have sedation if it were available. Twenty-five (35%) claimed to have received sedation for dental treatment in the past. CONCLUSION: It was concluded that the availability of dental sedation was currently not matching the needs and demands of several patients who took part in the survey. Increased availability of dental sedation could remove a barrier to dental care for many highly anxious dental patients.

Trauma to an osseointegrated anterior dental implant: a case report.

Single tooth implant systems have been shown to offer a safe and highly predictable option for the replacement of anterior teeth. There is however, a paucity of evidence on the result of trauma to single tooth implant systems, particularly in the vulnerable anterior maxillary area. This article presents a report on the outcome of a traumatic incident to an osseointegrated single tooth implant.