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.

Oral Health of Children with Congenital Heart Disease at a Pediatric Health Science Centre.

PURPOSE: This study aimed to examine the oral health status of seniors residing in Providence Health Care (PHC) long-term care facilities in 2002 and 2012. METHODS: Staff dentists with the University of British Columbia Geriatric Dentistry Program made a complete oral health assessment of 799 elderly residents of 7 long-term care PHC facilities in 2002 and 381 residents in the 5 remaining PHC facilities in 2012. The 2012 data were divided into those for 275 residents who had received treatment in previous years and 106 new residents. All consenting residents were examined by dentists using the clinical oral disorder in elders (CODE) index detailing their medical and oral health status and medications. On completion of the oral health assessment, the dentist documented the need for specific dental treatment and reassessment. RESULTS: Comparing the cohorts from 2002 and 2012, the mean age of the residents who had CODE assessments increased from 85 years to 86 years, the proportion of men increased from 31% to 35%, the mean number of medical conditions per resident remained unchanged (2.6 to 2.5), but the mean number of prescribed medications has increased from 4.0 to 4.6. The percentage of residents with natural teeth increased from 56% to 76%. The proportion of edentulous residents recommended for denture-related treatment decreased from 21% to 10%. The 106 new residents in 2012 had higher treatment needs than the 275 original residents, but fewer required extractions than in 2002. Although the mean number of teeth per resident examined increased from 14.6 to 17.4 over the study period, the need for restorations remained at 20%, and the need for extraction of teeth decreased from 22% to 6%. The proportion of residents with healthy periodontium increased from 14% to 21%, but the need for dental hygiene services increased from 43% to 80%. CONCLUSIONS: The profile of long-term care residents who consented to an oral health assessment changed over the first decade of the new millennium, with an increase in mean age and number of prescribed medications, number of retained natural teeth and the need for dental hygiene services, but a decrease in the need for extractions.

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.

Oral health assessment practices and perceptions of North American paediatric cardiologists.

OBJECTIVE: Children with cardiac defects should have good oral health, particularly prior to cardiac surgery to minimize risks of infective endocarditis. The aim of the study was to examine the oral health assessment practices of North American cardiologists. METHODS: Online surveys were e-mailed to 1409 cardiologists. Cardiologists without paediatric patients or practicing in centres without cardiac surgical care were excluded. Surveys addressed oral health assessment practices for paediatric cardiac patients, and perceptions of the impact of oral health on cardiac care. RESULTS: The centre response rate was 69%, individual response rate 20%. Most cardiologists (96%) reported oral health was assessed as part of cardiac care. The most common time for assessment was prior to cardiac surgery (44%), with a quarter assessing by age 1 (28%). While most oral assessments involved a dentist (59%), 17% of cardiologists performed the oral assessment without the aid of a dentist. Four-fifths of cardiologists (83%) reported cancellation of cardiac surgery due to oral disease. Cardiologists who deferred assessment until prior to surgery had the highest experience of cancellation (96%). Assessments were delayed despite the common belief (89%) that children on pre-surgical high-calorie diets are at increased risk of oral disease. CONCLUSION: Assessments of oral health status were often deferred until immediately prior to cardiac surgery despite the cardiologist's perception that children with cardiac defects were at increased risk of oral disease and prior experience of surgical cancellation due to oral disease. Paediatricians may need to facilitate early oral assessment for these children.

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.

Mineral trioxide aggregate produces superior outcomes in vital primary molar pulpotomy.

PURPOSE: The purpose of this study was to investigate the outcomes of vital primary molar pulpotomy when there is no direct contact between eugenol and the vital pulp. Four pulpotomy techniques were compared: (1) ferric sulfate (FS) pulpotomy; (2) eugenol-free FS pulpotomy; (3) mineral trioxide aggregate (MTA) pulpotomy; and (4) FS/MTA pulpotomy. METHODS: The pulpotomy technique assigned to each molar was determined by random selection. Two blinded, disinterested raters classified each molar into 1 of 3 radiographic outcomes: (1) N=normal molar without pathologic change; (2) Po=pathologic change present, follow-up recommended; (3) Px=pathologic change present, extract. RESULTS: A total of 92 patients with 227 pulpotomy-treated molars returned for at least 1 recall examination. Median follow-up for molars was 24 months (range=12-38 months). MTA molars demonstrated significantly fewer Px radiographic outcomes than FS molars (P=.002, chi-square test). Eugenol-free FS molars demonstrated significantly more Px radiographic outcomes than MTA (P<.001, chi-square test) or FS/MTA (P=.002, chi-square test) molars. Significantly lower survival was demonstrated for eugenol-free FS molars compared to MTA molars (P=.02, log-rank test) over 6 to 38 months. CONCLUSIONS: Outcomes for mineral trioxide aggregate pulpotomy were superior to ferric sulfate and eugenol-free ferric sulfate pulpotomy after a median follow-up of 2 years.

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.

An experimentally calibrated finite element study of maxillary trauma.

A baseball injury to an instrumented human cadaver maxillae was simulated with a regulation (142 g) baseball traveling at 14 m s(-1). Measurements of strain were obtained with three-axis strain gauge rosettes located at the medial palate and both canine fossae. A three-dimensional finite element (FE) model of a dentate human maxilla was constructed from computed tomography scans of the skull of an adolescent. This three-dimensional mathematical model of the maxilla was deemed geometrically accurate by convergence testing when the model's degrees of freedom approximated 74 000. The simulated load case involved a transient dynamic impact to the medial maxilla with boundary conditions imposed at skeletal buttresses of the model. The model was calibrated through direct comparison with the displacements and principal strains gathered from experimental and epidemiological data. The comparison of experimental and calculated principal strains as a result of the simulated impacts revealed a 1.7-11.4% difference.

Prioritization for elective dental treatment under general anesthesia.

This paper describes the process and outcomes of an initiative to develop a system to prioritize operating room bookings for children who require elective dental treatment. This initiative had 3 objectives: to improve the timeliness of treatment in the operating room based on medical and dental need, to provide a means to identify and expedite the highest-priority cases when operating room time became available, and to document the prioritization of cases as a quality assurance measure. Each patient booked for treatment in the operating room was assigned a priority ranking based on a combination of their medical risk and dental status. Measures of interrater reliability between clinician raters were moderate to good. Use of the prioritization system demonstrated improved timeliness of treatment for urgent cases and the effects of additional measures taken to reduce the waiting list.

Development of ankylosis in permanent incisors following delayed replantation and severe intrusion.

Ankylosis is a predictable outcome for replanted incisors and for most severely intruded incisors. There is no treatment to arrest or reverse this periodontal ligament complication. Ankylosis of the incisors of preadolescents alters local alveolar growth and eventually produces tooth loss subsequent to resorption. Currently, clinical methods used to diagnose ankylosis in the early postinjury period include subjective assessments of percussion sound and mobility and quantitative devices such as the Periotest. This paper describes the progression of ankylosis in two preadolescent patients that sustained severe trauma to their maxillary central incisors. A number of clinical assessments for diagnosis of ankylosis were compared for their usefulness, reliability and suitability.

Ankylosis of traumatized permanent incisors: pathogenesis and current approaches to diagnosis and management.

Ankylosis is a known complication of replanted or severely intruded permanent incisors and can be diagnosed by the characteristic sound emitted when the tooth is tapped. The ankylosed incisor demonstrates a lack of physiologic mobility and, later, radiographic evidence of replacement resorption. If the patient is pre-adolescent or adolescent at the time of trauma, infraocclusion relative to adjacent teeth will become apparent during jaw growth. Despite considerable knowledge about the pathogenesis of ankylosis garnered from animal studies and observation of human replanted teeth, there is no known treatment to arrest this condition. Management techniques and rehabilitation options for addressing ankylosis and its consequences are supported by little evidence, do not appear to be widely adopted and do not offer any proven long-term benefit. Avulsion and severe intrusion of permanent incisors are rare injuries. Should the decision be made to intervene by replantation or reduction of the intrusion, the clinician must be prepared to diagnose ankylosis, identify its negative consequences and develop treatment plans accordingly.

Diagnosis of ankylosis in permanent incisors by expert ratings, Periotest and digital sound wave analysis.

The objectives of this investigation were to: (i) assess the reliability of expert raters to detect ankylosis from recordings of percussion sounds, (ii) measure differences in Periotest values (PTV) between ankylosed and non-ankylosed incisors and (iii) identify characteristic differences in recorded percussion sounds from ankylosed and non-ankylosed incisors using digital sound wave analysis. A convenience sample of healthy children (age range 7-18 years) was invited to participate. Ankylosis group children had one or more documented ankylosed maxillary incisors. Control group children had intact, non-ankylosed incisors. Digital recordings of percussion sounds and PTV were acquired for each incisor of interest. Four experienced pediatric dentists rated the randomized percussion sound pairs for the presence of ankylosis. Percussion sounds were also subjected to digital sound wave analysis. Overall agreement for the expert raters was substantial (kappa = 0.7). Intra-rater agreement was substantial to almost perfect (kappa = 0.6-0.9). Diagnosis of ankylosis demonstrated sensitivity of 76-92% and specificity of 74-100%. PTV from ankylosed incisors were statistically lower than PTV from non-ankylosed incisors. Ankylosed incisor digital sound wave signals exhibited significantly more energy in high-frequency bands than non-ankylosed incisors. This investigation demonstrated that: (i) experienced pediatric dentists reliably detected ankylosis by percussion sound alone; (ii) PTV for ankylosed incisors were statistically lower than PTV from non-ankylosed incisors; and (iii) ankylosed incisors exhibited a higher proportion of their signal energy in high-frequency bands.

Medicolegal aspects of replanting permanent teeth.

Replantation of a permanent tooth is an intervention that carries the same responsibilities in terms of informed consent as a surgical procedure. Unlike many procedures that can be planned in advance, an avulsion requires decision-making shortly after the injury, often by a distraught patient or parent. Under these circumstances, patients or parents prefer, or may even pressure, clinicians to make the replantation decision for them.Later, the parents may seek advice of other professionals or be confronted by lay opinions or Internet information that may lead them to doubt the decision or even feel betrayed by the dentist who provided the acute care. This article uses an actual parent complaint to illustrate the medicolegal aspects of the replantation decision and describe measures to be taken by the clinician faced with this situation.