Interactive computer-assisted learning as an educational method for learning pediatric interproximal dental caries identification.

OBJECTIVE: We developed a web-based tool to measure the amount and rate of skill acquisition in pediatric interproximal caries diagnosis among pre- and postdoctoral dental students and identified variables predictive for greater image interpretation difficulty. STUDY DESIGN: In this multicenter prospective cohort study, a convenience sample of pre- and postdoctoral dental students participated in computer-assisted learning in the interpretation of bitewing radiographs of 193 children. Participants were asked to identify the presence or absence of interproximal caries and, where applicable, locate the lesions. After every case, participants received specific visual and text feedback on their diagnostic performance. They were requested to complete the 193-case set but could complete enough cases to achieve a competency performance standard of 75% accuracy, sensitivity, and specificity. RESULTS: Of 130 participants, 62 (47.7%) completed all cases. The mean change from initial to maximal diagnostic accuracy was +15.3% (95% CI, 13.0-17.7), sensitivity was +10.8% (95% CI, 9.0-12.7), and specificity was +15.5% (95% CI, 12.9-18.1). The median number of cases completed to achieve competency was 173 (interquartile range, 82-363). Of these 62 participants, 45 (72.6%) showed overall improvement in diagnostic accuracy. Greater numbers of interproximal lesions (P < .001) and the presence of noninterproximal caries (P < .001) predicted greater interpretation difficulty. CONCLUSIONS: Computer-assisted learning led to improved diagnosis of interproximal caries on bitewing radiographs among pre- and postdoctoral dental students.

A Comparison of Primary Maxillary Incisor Zirconia and Composite Resin Strip Crowns: A One-year Feasibility Study.

PURPOSE: The purpose of this study was to compare one-year clinical outcomes of primary incisor strip crowns (SCs) and zirconia crowns (ZCs) and determine the frequency of pulp therapy associated with each technique. METHODS: Children aged 18 to 48 months were randomly assigned to a ZC group or SC group. Each incisor was rated as intact (I), damaged (D), or requiring treatment (TR) six and 12 months following placement. RESULTS: Seventy-six ZCs and 101 SCs were placed for 59 participants; ZCs were more likely to be rated I than SCs at six months (odds ratio [OR] equals 4.2; P=0.01) and 12 months (OR equals 4.0; P=0.02). There was no statistical difference in the frequency of pulp therapy between groups (OR equals 0.8; P=0.70). There were no deviations from treatment randomization in either group. CONCLUSIONS: Zirconia crowns were more likely than strip crowns to be rated as intact at six or 12 months after treatment. The frequency of pulp therapy was not statistically different between groups.

The Cost of Treating Caries-Related Complaints at a Children's Hospital Emergency Department.

OBJECTIVES: To determine the number and diagnoses of caries-related complaints presenting at Canada's largest children's hospital emergency department (ED) and the costs associated with treatment over 5 years. METHODS: We carried out a retrospective review of the health records of all children who presented to The Hospital for Sick Children, Toronto, with caries-related emergency complaints from 1 January 2008 to 31 December 2012. A caries-related complaint was defined as a chief complaint of pain or swelling resulting from the sequelae of dental decay (reversible pulpitis, irreversible pulpitis, abscess or cellulitis), as recorded in the chart by the treating physician or dentist. Visit information included chief complaint, final diagnosis, treatment rendered and patient disposition at discharge. Decision Support Services, a hospital department that analyzes resource use and associated costs, calculated the institutional costs for the episodes of emergency care. RESULTS: There were 1081 visits over the 5-year period, with a 19% increase in visits over that time. The most common presenting complaint was pain (50.8%) and the most common diagnosis abscess (35.6%). A dentist was consulted for 60.0% of the children and dental treatment in the ED was provided for 25.9%. The mean cost of treatment per patient was Can$575.17 (95% confidence interval $501.91-$648.43). CONCLUSIONS: Over the 5-year study period, dental visits to this tertiary care pediatric hospital increased. The most common complaint was pain, and the diagnosis for about a third of these cases was abscess. Dental consultation was often included in the management of these patients and the resultant cost of these visits was about Can$600/patient.

Comparison of Ferric Sulfate Combined Mineral Trioxide Aggregate Pulpotomy and Zinc Oxide Eugenol Pulpectomy of Primary Maxillary Incisors: An 18-month Randomized, Controlled Trial.

PURPOSE: The purpose of this study was to compare outcomes and survival of ferric sulfate with mineral trioxide aggregate (FS+MTA) pulpotomy and root canal therapy (RCT) in carious vital primary maxillary incisors. METHODS: In this parallel group noninferiority trial, asymptomatic carious vital primary incisors with pulp exposure in healthy 18- to 46-month-olds were allocated randomly to receive FS+MTA pulpotomy or RCT between September 2010 and September 2012. Each incisor was classified into one of the following radiographic outcomes: N (incisor without pathologic change); Po (pathologic change present, follow-up recommended); Px (pathologic change present, extract.) Clinical findings and incisor survival were secondary outcomes. RESULTS: Seventy subjects were enrolled with a total of 172 incisors. Twelve- and 18-month radiographic outcomes demonstrated no statistical difference between FS+MTA pulpotomy and RCT incisors for Px outcomes (P=0.38; odds ratio equals 0.60; 95 percent confidence interval equals 0.19 to 1.89; chi-square test). There was no statistical differences in clinical outcomes for FS+MTA pulpotomy and RCT at 12 and 18 months (P=0.51; Fisher's exact test) or survival for FS+MTA pulpotomy and RCT incisors (P=0.11; log-rank test). CONCLUSIONS: Ferric Sulfate with Mineral Trioxide Aggregate (FS+MTA) is an alternative to RCT for vital primary incisors.

Suspected intraoperative anaphylaxis to gelatin absorbable hemostatic sponge.

Anaphylaxis under anesthesia is a life-threatening medical emergency that requires rapid identification and treatment. Allergies to agents with which the general population are likely to come into contact are usually identified, but patients are exposed to uncommon agents during anesthesia and surgery. Here, we describe a case of anaphylaxis under anesthesia implicating Gelfoam sponges.

Clinical relevance of access targets for elective dental treatment under general anesthesia in pediatrics.

OBJECTIVE: To evaluate the clinical relevance of access targets for elective dental procedures performed under general anesthesia at The Hospital for Sick Children in Toronto, Ontario, by assessing incremental changes in the burden of dental disease over wait times for such procedures. METHODS: Children scheduled for elective dental procedures under general anesthesia were assigned a priority according to the dental diagnosis and the medical risk status. Each priority level was defined by a specific diagnostic code and access target (maximum acceptable wait time). The dental records of children who underwent dental procedures with general anesthesia between June 2005 and December 2008 were assessed retrospectively. A novel assessment scale was used to measure the cumulative burden of dental disease during the waiting period. RESULTS: A total of 378 children (age range 10 months to 17 years) met the inclusion criteria. Statistically significant correlations were identified between disease burden and wait times for priority group IV (access target 90 days) (p=0.004), for the entire sample (p<0.001), for children with advanced dental caries and low medical risk (p=0.005), for patients with comorbidities (p=0.036), for healthy patients (p<0.001), for females (p=0.014) and for males (p=0.008). The mean cumulative burden of disease over time did not differ between matched groups with and without comorbidity (p=0.38). CONCLUSIONS: A trend suggestive of increasing burden of dental disease for children with longer wait times for elective dental procedures involving general anesthesia was found, but it was not clinically significant. Refinements in the assessment scale and a better understanding of the natural history of dental disease will likely be useful in developing clinically relevant access targets.

Effects of severe dentoalveolar trauma on the quality-of-life of children and parents.

BACKGROUND/AIM: This investigation assessed the effects of dental trauma on the perception of pain and quality of life (QoL) of patient-parent pairs for a year following severe injuries. SAMPLE: A visual analogue scale (VAS) was used to assess the pain of injury and treatment for 27 individuals 8-20 years and their parents. The Child Oral Health Quality of Life (COHQoL) survey was used to assess the effects of dental injuries on the QoL of 23 children aged 8-14 and their parents. RESULTS: Mean VAS scores revealed that all patients and parents perceived the pain of initial injury to be significantly greater than pain of splint removal (P < or = 0.05) and that pain decreased in a stepwise manner from injury through emergency treatment to splint removal. The COHQoL questionnaire demonstrated a profound and continuing effect on children and their parent's QoL following severe dental injury. The initial parental COHQoL score was significantly greater than the 12-month score (P < or = 0.05) in both 8-10 and 11-14- year-olds. The COHQoL results indicated a measurable reduction in the QoL of patients and parents was still present 12-months after the injuries. At the end of one-year children were still affected by the social and well-being aspects of the injury yet parents exclusively reported that one-year effects were limited to their children's oral symptoms and functional limitations. CONCLUSIONS: Severe dental injuries produce initial and ongoing pain. Detrimental effects on the QoL of both children and parents are still present at one-year and these long-term effects are different for children and parents.

Characterization of root surface periodontal ligament following avulsion, severe intrusion or extraction: preliminary observations.

This study employed novel topographic and histological techniques to assess remaining periodontal ligament (PDL) in a convenience sample of avulsed and intruded human permanent incisors and extracted premolars. Seventeen human teeth (eight avulsed, five severely intruded and four uninjured extracted) were evaluated for the distribution and physical characteristics of adherent root surface PDL. The topographic distribution of PDL was assessed by staining roots with malachite green and determining the proportion of remaining PDL within selected regions on four aspects of each tooth. In order to characterize mechanical damage to PDL, serial transverse sections of roots were stained with hematoxylin and eosin and examined at magnifications of 40x to 800x. The sections were photographed and imaging software was used to calculate the percentage of remaining PDL in the circumference of each root section. Topographic analysis demonstrated that 54% of the PDL remained on roots of avulsed and severely intruded incisors and 36% of the PDL remained on the extracted single-rooted premolars. Examination of serial transverse root sections revealed that 58% of the PDL remained on roots of avulsed or severely intruded incisors and 54% on extracted premolars. Avulsed and severely intruded incisors demonstrated similar amounts of retained PDL. In both injuries, almost half of the root surface was denuded of PDL.

Replantation of permanent incisors in children using Emdogain.

The aim of this study was to determine whether application of an enamel matrix protein derivative, Emdogain (Biora AB Malmo, Sweden) to the root surface of avulsed permanent incisors would improve postreplantation outcomes in a pediatric population. Between June 1999 and May 2002, 25 avulsed permanent maxillary incisors (22 centrals and three laterals) were treated with Emdogain and followed for up to 32 months, mean duration 20.6 months (range: 6.9-32.5 months). Mean patient age at the time of treatment was 12.0 years (range: 7.7-17.6 years) and mean extra-alveolar duration was 185 min (range: 100-300 min). At the end of their follow-up each of the replanted incisors demonstrated radiographic evidence of replacement root resorption and clinical evidence of ankylosis. None of the replanted teeth were affected by inflammatory root resorption and there was no evidence of infection. When compared with the control samples from Barrett and Kenny (Endod Dent Traumatol 1997;15:269-72.) and Andersson et al. (Endod Dent Traumatol 1989;5:38-47.) this sample treated with the Emdogain protocol demonstrated significantly less root resorption than either of the control samples (anova, P < 0.0001). Although the Emdogain protocol did not produce periodontal regeneration, it did eliminate inflammatory resorption and infection and led to significantly less root resorption compared with the two historical controls.

Emergency trauma: treating the unexpected.

Patients expect their dentist to be capable of priority management of their dental injury. However, unless a dentist regularly attends emergency calls at a hospital or clinic, he or she may be "rusty" when faced with the unexpected arrival of an injured, upset patient. The dentist must deal with the schedule disruption, prioritize treatment or referral, deal with informed consent for minors and adults, and sort out contradictory treatment protocols that are often out of date and inconsistent with scientific evidence.

Socio-economic burden of permanent incisor replantation on children and parents.

This study describes the socio-economic burden and attitudes of children and their parents following replantation of avulsed incisors. Records of 80 patients with 99 avulsion injuries treated in a teaching hospital clinic from 1988 to 1999 were reviewed. Mean age at time of injury was 10.6 years (range = 6.6-17.7 years). Complete records for a minimum of 1 year were obtained for 43 patients with 60 replanted incisors. Mean treatment procedures provided during the first year included 5.5 diagnostic periapical radiographs, 1.9 occlusal radiographs, 1.3 pulpectomies, and 2.7 pulp medicament applications. The mean estimated treatment cost and direct time (dentist) for first-year post-trauma management was 1465 dollars CAD and 7.2 h, respectively. Treatment costs were significantly higher during the first year post-trauma for patients who had their incisors extracted (P = 0.04), but there was no significant difference in direct treatment time between the two groups (P = 0.19). Twenty-one patient-parent pairs were surveyed for a number of qualitative factors. Ninety per cent of patients and 86% of parents reported that school and work time was lost. Even after having gone through the painful experience of replantation, the demands of recall, and in some cases, extraction, the majority of patients (67%) and parents (81%) stated that they would have still made the same (replantation) decision. Patient and parent responses were not statistically different (P = 0.453). Almost half the parents stated they would be willing to pay over 2000 dollars CAD to save an incisor. Patients rated retention of an incisor as significantly more important than infraocclusion. This is the first study to quantify the treatment burden of replantation of avulsion injuries exclusively in the pediatric population. This study describes the socio-economic burden and responsibilities of patient/parent and dentist and their role in informed consent.

Avulsions and intrusions: the controversial displacement injuries.

Avulsions and intrusions are the most complicated and controversial displacement injuries of permanent teeth. Clinical guidelines published by authorities such as the American Association of Endodontists, the Royal College of Surgeons of England and the International Association of Dental Traumatology are inconsistent. While a certain amount of inconsistency might be expected, some of these guidelines recommend treatments that are experimental or have not incorporated research information from the past 5 years, and in one case the guidelines incorrectly describe the nature of Hank's balanced salt solution. Recent laboratory studies support previous clinical outcome studies in emphasizing that only for teeth replanted within 5 minutes of avulsion is there a chance of regeneration of the periodontal ligament and normal function. Teeth replanted beyond 5 minutes will take another path, that of repair followed by root resorption, ankylosis and eventual extraction. Dentists should explain these outcomes at the time of the replantation decision. Severe intrusions also have predictable outcomes. Teeth intruded beyond 6 mm cannot regenerate a functional periodontal ligament and so are prone to root resorption and eventual extraction as well. In this situation the decision is one of immediate extraction or repositioning, with the understanding that it is inevitable that the tooth will eventually be extracted. Authoritative clinical guidelines available on the Internet provide the clinician with useful outlines for treatment. However, individual inconsistencies stimulate academic controversies and, in some cases, clinical misdirection.

Clinical outcomes for permanent incisor luxations in a pediatric population. II. Extrusions.

A longitudinal outcome study was undertaken to identify variables that significantly influenced outcomes for extruded permanent maxillary incisors of children and adolescents. Clinical and radiographic data was available for 35 patients (18 males, 17 females) representing 55 incisors. Mean age at the time of injury was 10.6 years (range: 7.1-17.8 years). Mean time elapsed to follow up was 1320 days (range: 423-2887 days). Survival analysis was used to identify variables significantly related to the prognosis of these teeth. The loss of an incisor following extrusion was uncommon as only one tooth (1/55) required extraction. There was no statistically significant difference in survival between severely extruded teeth and avulsions that had been stored in physiological media (P > 0.10). Pulp necrosis (PN) was the most common complication following injury (43%) and it most often occurred during the first year. Although not statistically significant, a trend towards increased PN was found with more severely extruded teeth (P = 0.20, relative risk = 2.08). Pulp canal obliteration (PCO) was the second most common outcome (35%). The degree of extrusion was proven to be significantly associated with the development of PCO (P = 0.03, relative risk = 0.33). Root resorption was an uncommon outcome (3/55). This study represents the first outcome data on extrusions to permanent maxillary incisors in an exclusively pediatric population.

Clinical outcomes for permanent incisor luxations in a pediatric population. I. Intrusions.

A longitudinal outcome study was undertaken to identify variables that significantly influenced tooth survival as well as pulpal and periodontal outcomes for intruded permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 26 patients (19 males, 7 females) that represented 31 permanent maxillary incisors. Mean age at the time of injury was 9.3 years (range = 5.5-17.8 years). Mean time elapsed to follow up was 1380 days (range = 65-3394 days). Survival analysis was used to identify variables significantly related to the survival and pulp necrosis (PN) for these incisors. Proportional hazards regression yielded significant prognostic models for tooth survival and the diagnosis of PN (P < 0.05). Incisors intruded > 6 mm had significantly decreased survival compared with incisors intruded < 3 mm (5-year survival, 0.45 and 1.0, respectively, (P < 0.05)). Complex crown fractures were significantly related to the development of PN (P < 0.05). Logistic regression analysis showed that treatment method and severity of intrusion were related to the presence of replacement root resorption (P < 0.05). This study represents the largest sample of intruded permanent incisors examined in an outcome study of children and adolescents exclusively.

Clinical outcomes for permanent incisor luxations in a pediatric population. III. Lateral luxations.

A longitudinal outcome study was designed to identify variables that influenced tooth survival as well as pulpal and periodontal outcomes of laterally luxated permanent maxillary incisors of children and adolescents. All cases were treated between June 1988 and June 1998 in a teaching hospital clinic. Clinical and radiographic data were collected for 42 patients (26 males, 16 females) that represented 58 permanent maxillary incisors. Mean age at the time of injury was 11.4 years (range: 6.3-17.8 years). Mean follow-up time was 1460 days (range: 183-3905 days). In the entire sample (n = 58), no incisors required extraction. Survival analysis and logistic regression were used to identify variables significantly related to the survival and healing outcomes of these incisors. Pulp necrosis (PN) (40%) and pulp canal obliteration (PCO) (40%) were common healing complications. Proportional hazards (Cox) regression showed that PN develops within the first year. Logistic regression demonstrated that root development (P = 0.3, PN; P = 0.8, PCO) and extent of lateral luxation (P = 0.5, PN; P = 0.9, PCO) were not significantly related to PN and PCO. This study provides the first report of incisor survival in children and adolescents following lateral luxation injuries.