Randomized Clinical Trial of Intraosseous Methylprednisolone Injection for Acute Pulpitis Pain.

INTRODUCTION: The present study reports the results of a randomized clinical trial comparing local intraosseous methylprednisolone injection and emergency pulpotomy in the management of acute pulpitis on efficacy, safety, and efficiency end points. METHODS: After providing prior informed written consent, 94 patients consulting for acute irreversible pulpitis pain at university-affiliated teaching hospital dental clinics in Dakar, Senegal were randomly assigned to either the methylprednisolone treatment group (n = 47) or the pulpotomy treatment group (n = 47). Patients were followed up at 1 week and assessed 6 months later to evaluate the therapeutic outcome of their treatment. RESULTS: At day 7 the patients in the methylprednisolone group reported less intense spontaneous and percussion pain in the day 0-day 7 period than the patients in the pulpotomy group. Methylprednisolone treatment took approximately 7 minutes (4.6-9.3) less to accomplish than pulpotomy (or about half the time). No difference in the therapeutic outcome was found between the 2 treatment groups at 6 months (all credible intervals span 0). CONCLUSIONS: This study establishes that methylprednisolone injection for acute pulpitis is relieved by a minimally invasive pharmacologic approach more effectively than by the reference pulpotomy and conserves scarce dental resources (ie, endodontic equipment and supplies, dental surgeon's time).

Use of a new retrograde filling material (Biodentine) for endodontic surgery: two case reports.

Mineral trioxide aggregate (MTA) is considered at the present time as the gold standard for root-end filling in endodontic surgery. However, this biocompatible material presents several drawbacks such as a long setting time and handling difficulties. The aim of this article is to present a new commercialized calcium silicate-based material named Biodentine with physical improved properties compared to MTA in a clinical application. Two endodontic microsurgeries were performed by using specific armamentarium (microsurgical instrumentation, ultrasonic tips) under high-power magnification with an operatory microscope. Biodentine was used as a root-end filling in order to seal the root canal system. The two cases were considered completely healed at 1 year and were followed for one more year. The 2-year follow-up consolidated the previous observation with absence of clinical symptoms and radiographic evidence of regeneration of the periapical tissues.

Clinical study evaluating the effect of bevacizumab on the severity of zoledronic acid-related osteonecrosis of the jaw in cancer patients.

This study aimed to evaluate the effect of bevacizumab (BVZ) on the severity of osteonecrosis of the jaw (ONJ) in a cohort of cancer patients treated with intravenous zoledronic acid (ZA). We reviewed 42 oncologic patients with ONJ between 2007 and 2010. Only patients with solids tumors and who had received ZA were included. Data analyses included age, sex, underlying disease, ZA and BVZ dosages, dental history and ONJ characteristics. Of the 42 ONJ patients treated with ZA, 10 also received BVZ. In the 10 ZA/BVZ patients, the mean duration of ZA treatment at the time of ONJ diagnosis was 12.4 months (±6.8), compared to 22.9 months (±4.8) in the 32 patients who received ZA only (p<0.05). Cox's model analysis of the delay to ONJ diagnosis confirmed the impact of BVZ on ONJ diagnosis. In the ZA/BVZ-treated group, 7 (70%) patients developed spontaneous osteonecrosis. Multiple logistic regression analysis showed that ZA/BVZ is associated with increased risk of developing spontaneous ONJ (OR 6.07; 95% CI, [1.3-28.2], p<0.05). And finally, the number of ONJ lesions was increased in the ZA/BVZ-treated group compared to the ZA group (p<0.01). Other clinical conditions as type of tumor (prostate, breast…), cancer severity or other chemotherapy drugs also could be involved in ONJ evolution. However, this study demonstrates for the first time the potential negative influence of BVZ on the incidence and severity of ONJ in patients receiving ZA. Within the study limits, our results suggest that combination ZA/BVZ treatment may possibly predispose to the development of spontaneous and earlier ONJ.

Osteonecrosis of the jaw and nonmalignant disease: is there an association with rheumatoid arthritis?

OBJECTIVE: To review cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) occurring in association with benign disease and to describe and compare the clinical course and outcome for patients with BRONJ and rheumatoid arthritis (RA) or osteoporosis. METHODS: We retrospectively reviewed observations of all patients referred for treatment and followup for BRONJ from January 2007 to December 2011. Only patients with malignant disease were excluded. Demographic data, medical history, maxillofacial findings, BRONJ treatment, and followup were reviewed for each case. RESULTS: Over a 5-year period, we diagnosed 112 patients with BRONJ. Among these patients, 15 received bisphosphonate (BP) treatment for nonmalignant disease (mean age 65.7 ± 19.8 yrs, 80% women). Patients received BP for a variety of reasons: 8 (53%) to prevent osteoporosis in association with underlying RA; 6 (40%) to prevent idiopathic osteoporosis; and 1 (7%) to treat ankle algodystrophy. The mean oral BP exposure period was 48.4 months (median 36 mo). In 13 cases (86.6%), BRONJ was diagnosed following dental extraction. Of the 8 patients with RA, 5 (62.5%) were taking prednisone at the time of the discovery of BRONJ. Major surgery, sequestrectomy, or alveolectomy was performed in 9 patients (60%), all of whom healed within 3 to 36 months (mean 11.5 mo). Comparative analysis of all the variables showed no statistically significant differences between patients with RA and others. CONCLUSION: ONJ is a rare adverse effect of BP therapy, especially when administered orally. Within the limits of our study, we were unable to demonstrate a difference in BRONJ disease spectrum, clinical course, or outcome between patients with and those without RA.

Glutamate control of pulpal blood flow in the incisor dental pulp of the rat.

Glutamate is present in primary sensory afferents innervating the dental pulp and is known to exert vasoactive effects. The aims of this study were (i) to assess pulpal blood flow (PBF) after glutamate infusion in the dental pulp and (ii) to observe the distribution of glutamatergic nerve fibers expressing the vesicular transporters of glutamate (VGluT). The PBF was monitored with laser Doppler flowmetry before and after glutamate (0.5 M) infusion in the dental pulp vs. saline infusion. Immunochemistry for VGluT1, 2, and 3 was performed in addition to immunochemistry for the vascular and neuronal markers smooth-muscle actin (SMA), isolectin B4 (IB4), and calcitonin gene-related peptide (CGRP). Glutamate infusion resulted in a PBF increase that lasted for 60 s. Positive immunolabeling was observed for the three glutamate transporters, but was more pronounced for VGluT3. Moreover, VGluT3 immunoreactivity was observed within nerve fibers entering the dental pulp and terminating at the periphery and at the vicinity of odontoblasts. Also, VGluT3 was colocalized with the vascular marker SMA, and in some nerve fibers with IB4, but not with CGRP. This study provides support for a control of dental pulp microcirculation by neurons expressing VGluT3.

Cortical stimulation and tooth pulp evoked potentials in rats: a model of direct anti-nociception.

While the effect of cortex stimulation on pain control is widely accepted, its physiological basis remains poorly understood. We chose an animal model of pain to study the influence of sensorimotor cortex stimulation on tooth pulp stimulation evoked potentials (TPEPs). Fifteen awake rats implanted with tooth pulp, cerebral cortex, and digastric muscle electrodes were divided into three groups, receiving 60 Hz, 40 Hz and no cortical stimulation, respectively. TPEPs were recorded before, one, three and five hours after continuous stimulation. We observed an inverse relationship between TPEP amplitude and latency with increasing tooth pulp stimulation. The amplitudes of the early components of TPEPs increased and their latency decreased with increasing tooth pulp stimulation intensity. Cortical stimulation decreased the amplitude of TPEPs; however, neither the latencies of TPEPs nor the jaw-opening reflex were changed after cortical stimulation. The decrease in amplitude of TPEPs after cortical stimulation may reflect its anti-nociceptive effect.

Somatosensory evoked response and jaw opening reflex elicited by tooth pulp stimulation in awake freely moving rats.

OBJECTIVE: Investigation of pain and nociception refers to different models. Depending upon the intensity of stimulation, unmyelinated pulpal fibers or periodontal A-fibers can be stimulated producing a short or a long latency jaw opening reflex of the digastric muscle. This paper investigates the different components of the jaw opening reflex in addition to the correlation between afferent fibers involved in the cortical evoked response. DESIGN AND SETTING: Fifteen awake male rats were implanted with tooth pulp stimulation electrodes, digastric and cortical recording electrodes. Ten rats were submitted to recordings after a single tooth pulp stimulation, while five rats were using conditioning and test stimulation. Tooth pulp evoked potentials and digastric EMG were simultaneously recorded. A multiresolution denoising method was used for signal processing. RESULTS: Following tooth pulp stimulation, a cortical response was produced including the following peaks: P6.5 +/- 1.1, N11 +/- 1.2, P17 +/- 1.2, P27 +/- 2.9, N53 +/- 7.5, P69 +/- 5.8, P88 +/- 13, N160 +/- 9.7, P204 +/- 14.2. The distribution and amplitude of these peaks are correlated to the stimulation intensity (r=0.96, p<0.01). An interaction between the different components of the jaw opening reflex was identified on EMG, following a conditioning shock, where a cortical evoked response showed a P30 +/- 2.7 peak which was observed concurrently with the jaw opening long latency reflex. CONCLUSION: Our results identify the interaction between the different components of the jaw opening reflex and the correlation to the cortical evoked response.

[Prescription of aspirin in recent acute painful disorders: results of a survey among French general practitioners]. / Prescription d'aspirine dans les douleurs aiguës récentes: résultats d'une enquête en médecine générale.

AIMS: To analyse recent acute painful conditions for which general practitioners (GPs) would prescribe aspirin. METHODS: Prospective observational study investigating GPs' prescription of aspirin to adult patients with acute pain of < or =5 days of duration. Pain intensity was graded on a 100 mm visual analogue scale (VAS) prior to and at the 48th hour of aspirin therapy. RESULTS: 4765 patients (53.9% males), aged 42.6 +/- 14.7 years, with recent acute pain (2.2 +/- 1.2 days) were enrolled. Aspirin was prescribed at a mean daily dose of 3g, for musculoskeletal pain (40.8%), headaches and/or migraine (30.7%), ENT pain (23.2%) or dental pain (9.5%), some patients having complained of different types of pain. Pain relief was assessable in 3793 patients (79.6%). In this population, pain intensity was reduced by 65% within 48 hours, from 63.5 +/- 16.7 mm to 22.2 +/- 17.1 mm on the VAS. The rate of responders (decrease > or =75 % on VAS) was 39.6%; however it varied markedly across the different painful disorders. CONCLUSION: Our survey suggests that GPs may prescribe aspirin for acute pain states similar to those for which they prescribe over-the-counter non aspirin non steroidal anti-inflammatory drugs.

Taste deficits related to dental deafferentation: an electrogustometric study in humans.

Dental treatments, the prevalence of which increases with age, can cause orofacial somatosensory deficits. In order to examine whether they may also affect taste sensitivity, electrogustometric thresholds were measured at 9 loci on the tongue surface in 391 healthy non-smoking, non-medicated subjects. Results showed that the greater the number of deafferented teeth, the higher the thresholds. Irrespective of age, subjects with more than 7 deafferented teeth exhibited significantly higher thresholds than subjects with fewer than 7 deafferented teeth. Conversely, across age groups, no statistical difference was observed among subjects with no, or few, deafferented teeth. Hence, a taste deficit, which was not correlated to aging, was observed. An association was noticed between the location of taste deficits and the location of deafferented teeth. Higher thresholds at anterior sites, with no possible traumatic injury relationship, suggested that neurophysiological convergence between dental somatosensory and taste pathways - possibly in the nucleus tractus solitarius - could be responsible for these relative decreases of taste sensitivity when dental afferences were lacking. Among trigeminal contributions, lingual nerve and inferior alveolar nerve may synergize taste.

Trigeminal modulation of gustatory neurons in the nucleus of the solitary tract.

Electrophysiological methods were used to investigate the effects of trigeminal nerve stimulation or transection on responses of single gustatory neurons in the nucleus of the solitary tract (NTS) to tastants (NaCl, sucrose, citric acid, monosodium glutamate) in pentobarbital-anesthetized rats. Unilateral transection of the lingual nerve, or the mandibular branch of the trigeminal nerve, resulted in significant reductions (by 21 and 29%, respectively; P<0.01) in tastant-evoked responses, with no further effect following bilateral transection. Electrical stimulation of the central cut end of the mandibular nerve directly excited nine of 14 gustatory NTS units. For these units, central mandibular stimulation facilitated the tastant-evoked responses in six, depressed responses in three, and had no effect in five. Facilitation of tastant-evoked responses peaked 4 min after mandibular stimulation and recovered within 8 min. Electrical stimulation of the peripheral cut end of the mandibular nerve significantly reduced tastant-evoked responses in nine other NTS units, with a maximal reduction at 4 min post-stimulation followed by recovery. Stimulation of the superior cervical sympathetic ganglion did not affect NTS tastant-evoked responses. These results suggest the presence of complex central modulation of NTS neurons by trigeminal afferents, as well as a peripheral depressant effect on gustatory processing possibly mediated via neuropeptide release from trigeminal nerve endings in the tongue.