Root canal treatment of compromised teeth as alternative treatment for patients receiving bisphosphonates: 60-month results of a prospective clinical study.

AIM: This 60-month prospective study aimed to evaluate tooth survival and healing rates after root canal treatment in patients taking bisphosphonates (BPs). Secondary outcomes were complications and clinical variables observed during and after treatment. METHODS: Root canal treatment was performed using manual K-file canal instrumentation and a carrier-based filling technique with an epoxy resin-based sealer. Teeth without adequate root/crown integrity were restored by trained operators at the tissue level (TL group) to prevent occlusal/mechanical stress and to enable periapical lesion healing without the risk of root fracture. Other teeth were restored with normal occlusal contacts (OC group). Healthy patients who had undergone one or more root canal treatments of the same type constituted the control group. The relationships of the following variables to survival and health status were examined (chi-squared test and multivariate analysis, P = 0.05): age, gender, smoking habit, tooth location, treatment type, BPs treatment, BPs exposure, initial periapical index (PAI) and occlusal restoration. Survival curves were constructed using Kaplan-Meier analysis, with extraction serving as the end-point. RESULTS: In total, 65 patients with 109 root canal-treated teeth who were taking BPs were included. At 60 months, data from 57 patients (52F, 5M; median age 65.7 ± 8.6 years) who had undergone 96 root canal treatments were analysed (drop-out rate = 16.9%). The survival rate was 85%, and the success rate was 76%. The control group consisted of 46 patients (21F, 25M; median age 60.3 ± 7.2 years) who had undergone 102 root canal treatments. The survival rate was 88%, with 12 teeth lost during follow-up. The success rate was 73%. In the BP group, 55 teeth were restored normally (OC group) and 41 teeth were restored at the tissue level (TL group). No difference in the success or survival rate was observed between the BP and control groups (P > 0.05). Univariate Kaplan-Meier analysis revealed that only tooth type significantly affected survival status in the BP group. The analysis revealed the clinical relevance of smoking, tooth location and initial PAI on patients' health status (P < 0.05). CONCLUSION: Root canal treatments and post-endodontic restoration with tissue-level filling procedures represent a safe approach for severely damaged teeth in patients receiving BPs having comparable results to root filled teeth restored with occlusal contacts and to the control group.

Differential diagnosis between a granuloma and radicular cyst: effectiveness of magnetic resonance imaging.

AIM: To investigate the diagnostic reliability and accuracy of magnetic resonance imaging (MRI) to differentiate periapical lesions of endodontic origin and to compare the results with histopathological information. METHODOLOGY: The radiolucent periapical jaw lesions of 34 patients, which were surgically enucleated, were investigated by two radiologists using MRI, based on the same six criteria, to categorize the lesions as granulomas, radicular cysts or others. After apicoectomies, two oral pathologists (blinded to the radiologist's diagnoses) analysed all specimens by referring to seven specific parameters and diagnosed the specimens as granulomas, radicular cysts or other conditions. The inter-rater agreements between the radiologists and pathologists in terms of MRI and histological diagnoses, respectively, along with the discriminant power of the adopted criteria and the accuracy of the MRI assessments compared with the histopathological results, were calculated. Cohen's kappa test was adopted to examine inter-rater agreement between the two radiologists and two pathologists. Guttman's lambda coefficient (λ6 ) was used to evaluate the internal consistency of the items used for the differential diagnosis by radiologists. The accuracy resulted from a receiver operator characteristic (ROC) analysis. RESULTS: A strong inter-rater reliability was observed between the two radiologists (k-statistic = 0.86, P = 0.0001) and the two pathologists (k-statistic = 0.88, P = 0.0001). The internal consistency of the diagnostic items was 0.605 for cysts and 0.771 for granulomas. The accuracy (true positives plus true negatives) of the radiologists was greater than that of the pathologists based on analysis (area under the curve = 0.87 and 0.91, respectively). CONCLUSIONS: The reliability and accuracy of MRI were high and comparable to histopathological reliability, highlighting the usefulness of this noninvasive technique as a pre-treatment diagnostic method for periapical endodontic lesions.

Delayed onset infections after lower third molar germectomy could be related to the space distal to the second molar.

The onset of delayed infection after lower third molar germectomy is influenced by the amount of distal space. This retrospective study aimed to determine whether the incidence of delayed onset infection is related to the space distal to the second molar. The ratio between the distal space and the crown width, measured according to the Ganss protocol on panoramic radiographs, was obtained for 218 surgical germectomies performed for orthodontic reasons in 134 patients. A delayed onset infection occurred following 20 germectomies at between 2 and 8 weeks after surgery; purulent exudates from the alveolus and swelling were present. In 16 of the 20 cases of infection, a Ganss ratio of <0.5 showed the almost complete absence of space distal to the second molar. This study found that the distal space was significantly and inversely correlated with delayed onset infection (P=0.004). From a clinical point of view, it is important for the surgeon to be aware that a higher Ganss ratio may indicate that a delayed onset infection is less likely to occur and that a lower Ganss ratio could indicate a greater likelihood of this type of infection, so that the patient can be properly informed.

Calcium silicate/calcium phosphate biphasic cements for vital pulp therapy: chemical-physical properties and human pulp cells response.

OBJECTIVES: The aim was to test the properties of experimental calcium silicate/calcium phosphate biphasic cements with hydraulic properties designed for vital pulp therapy as direct pulp cap and pulpotomy. METHODS: CaSi-αTCP and CaSi-DCDP were tested for ion-releasing ability, solubility, water sorption, porosity, ability to nucleate calcium phosphates, and odontoblastic differentiation­alkaline phosphatase (ALP) and osteocalcin (OCN) upregulation­of primary human dental pulp cells (HDPCs). RESULTS: The materials showed high Ca and OH release, high open pore volume and apparent porosity, and a pronounced ability to nucleate calcium phosphates on their surface. HDPCs treated with CaSi-αTCP showed a strong upregulation of ALP and OCN genes, namely a tenfold increase for OCN and a threefold increase for ALP compared to the control cells. Conversely, CaSi-DCDP induced a pronounced OCN gene upregulation but had no effect on ALP gene regulation. CONCLUSIONS: Both cements showed high biointeractivity (release of Ca and OH ions) correlated with their marked ability to nucleate calcium phosphates. CaSi-αTCP cement proved to be a potent inducer of ALP and OCN genes as characteristic markers of mineralization processes normally poorly expressed by HDPCs. CLINICAL RELEVANCE: Calcium silicate/calcium phosphate cements appear to be attractive new materials for vital pulp therapy as they may provide odontogenic/dentinogenic chemical signals for pulp regeneration and healing, and dentin formation in regenerative endodontics.

Jaw cysts diagnosed in an Italian population over a 20-year period.

BACKGROUND: Cysts of the jaws (JCs) are an important topic of oral pathology, but few epidemiological data are present in the literature, in particular about the potential of recurrence. The aim of this study was to describe a case series of JCs from a single institution, evaluating the frequency, the site, the age distribution, and the percentage of recurrence of all types of JCs. METHODS: All JCs present in the histological records of the Section of Anatomic Pathology of the University of Bologna at Bellaria Hospital from 1992 to 2012 were retrieved. RESULTS: A total of 1136 jaws cysts were obtained, of which 1117 (98.3%) were odontogenic and 19 (1.7%) were nonodontogenic. About odontogenic cysts (OCs), the most frequent was the radicular cyst (538 cases), followed by parakeratinized keratocystic odontogenic tumor (pKOT, 193 cases) and dentigerous cyst (120 cases). Among pKOT, 21 out of 193 cases (10.89%) showed a recurrence after a mean time of 4.5 years (range, 1-12 years). During follow-up (mean 11 years, range 1-19 years), all 3 cases of botrioid cysts, 12 out of 46 cases of unicystic ameloblastoma (26.09%), 2 out of 20 cases of calcifying OCs (10%) and 2 out of 538 cases of radicular cyst (0.37%) showed a recurrence. CONCLUSION: Our study confirms that the distribution pattern of JCs in Italy is relatively similar to other studies worldwide and emphasizes the importance of recognizing the different histological types of JCs for their potential local aggressive behavior.

Self-assessed bruxism and phobic symptomatology.

AIM: The aim of this observational study was to compare two samples of patients (identified, from a previous survey carried out in 2007, as self-assessed bruxers and not) on the basis of the presence of anxious/phobic symptoms, general and linked to an oral surgery. METHODS: Forty-three bruxers and 207 non-bruxers were identified; among these last ones a sub-sample of 89 subjects was randomly selected as control and analyzed. The instruments for data collecting were two self-administered psychological questionnaires: STAI-Y1, Phobia Scale by Marks-Sheehan, and supplementary items on specific dental fear/phobia. RESULTS: No significant differences were observed for age, gender and occupation data but interestingly bruxers are significantly more represented among widows/divorced and graduated in comparisons with non-bruxers. Alcohol consumers were more frequent in bruxers than in non-bruxers (55.8% and 12.4%, respectively; P=0.0001). Global anxiety (P=0.02), agoraphobia, claustrophobia, pathophobia, social phobia (P<0.05), are more frequent in bruxers as also a suffocation feeling (P=0.02). The severity of behaviours that aim to avoid the same situations that causes phobias is low and similar in the two groups. CONCLUSION: The involuntary habit of clenching is, in our opinion, reported by the patients who control their anxiety/phobias without avoiding behaviours, increasing the muscular activity at a level relevant to bruxism.

Prescriptions of NSAIDs to patients undergoing third molar surgery : an observational, prospective, multicentre survey.

BACKGROUND AND OBJECTIVES: Surgical extraction of an impacted third molar is generally followed by acute post-operative pain that has been shown to be primarily inflammatory. Thus, use of NSAIDs in this context is appropriate and has been shown to be effective. Several drugs are employed for this purpose, but no information exists on the reasons why preference is given to one rather than another. The principal objective of this study was to evaluate the pattern of administration of NSAIDs in patients undergoing surgery for impacted third molar extraction. The study also aimed to collect information on the efficacy, onset and duration of the analgesic effect of routinely prescribed NSAIDs and to assess the duration of treatment with these drugs and their tolerability. METHODS: This was an observational, multicentre, prospective survey. A total of 616 patients (38% male and 62% female) from the Italian Stomatology Clinics of the Universities of Bologna, Brescia, Cagliari, Chieti, Pavia, Pisa, Siena and Varese and from the Department of Oral and Maxillo-Facial Surgery of Semmelweis University, Budapest, were eligible for the study. Patients were evaluated over the 7 days following surgical extraction. NSAIDs were prescribed according to the normal prescribing habits of the centre and physician involved. The main outcomes of interest in the survey were the efficacy, onset and duration of analgesic effect, duration of therapy, and tolerability of the NSAIDs prescribed. RESULTS: Nimesulide was the most prescribed NSAID (68%), followed by diclofenac, ketoprofen and ibuprofen. Because of the low proportion of patients receiving other NSAIDs, these patients were considered a single treatment group for evaluation purposes. Nimesulide, especially when given before patients started experiencing pain after surgery, was more effective than other NSAIDs in reducing the severity of pain on the day of surgery, in delaying the time to maximum intensity of pain, in providing complete pain relief and in prolonging the duration of analgesic effect on the day of surgery. These results are consistent with the known anti-inflammatory and analgesic actions of nimesulide and with the important role of inflammation in the onset of pain after this type of surgery. CONCLUSION: These results confirm nimesulide as an effective reference drug for the treatment of post-operative dental pain and show that it has a positive benefit/risk profile in this setting.

Periodontal disease as a risk factor in pregnancy.

There is growing evidence that periodontal disease represents a risk factor for preterm delivery and premature membrane rupture. To prevent an oral inflammatory process evolving into a full-blown form of periodontitis, with possible severe repercussions on pregnancy outcome following systemic spread, future mothers should receive regular professional oral hygiene care throughout pregnancy.

Evaluation of osteoblast-like cell response to Proroot MTA (mineral trioxide aggregate) cement.

Some endodontic sealers have been shown to cause local and systemic effects, mainly due to microleakage of chemicals from the sealer. To avoid the risk of toxic effects in vivo, the biological compatibility of filling materials has to be assessed. In vitro compatibility of Proroot MTA cement in comparison with two different fillers used in clinical practice, was examined by testing the adherence, viability, proliferation and secretion of collagen of osteoblast-like cells. In our experimental system, Saos-2 cells challenged with Proroot MTA for 24 and 72 h showed a better behaviour than the cells exposed to the other compounds under assay. We found that the cells attached to the rough surface of Proroot MTA cement and spread onto the rough surface. Moreover, the cells on Proroot MTA were viable, grew, and released some collagen even at 72 h, while cell metabolism and growth was dramatically reduced onto sEBA and amalgam surfaces. A parallel behaviour was found after the cells were challenged with extracts of the different fillers. In conclusion, according to our in vitro study, Proroot MTA showed a good interaction with bone-forming cells: such behaviour may partially account for its satisfying clinical performance.

Management of bilaterally impacted mandibular second and third molars.

BACKGROUND: The authors present an interdisciplinary approach to treating bilateral impaction of mandibular second molars. CASE DESCRIPTION: A 22-year-old man had a bilateral deep horizontal impaction of his mandibular second molars. The mandibular third molars lay above and parallel to the second molars. After an orthodontic assessment, the authors decided to distally upright the third molars, remove them and then orthodontically reposition the second molars if they were not ankylosed. This combined orthodontic-surgical approach was successful. CLINICAL IMPLICATIONS: This case illustrates the importance of strong cooperation among various specialists to establish the optimal comprehensive treatment plan.

Gingival recession and toothbrushing in an Italian School of Dentistry: a pilot study.

The aim of this pilot study was to evaluate the prevalence of gingival recession at buccal tooth surfaces in a student population of Bologna University Dental School. A total of 55 subjects, attending the 1st and 5th year of the course were examined. The clinical examination involved assessment of plaque, calculus, width of keratinized gingiva, buccal probing depth and buccal gingival recession. Information about toothbrushing behavior was collected in an interview. The multiple regression analysis showed that level of education (p=0.002), toothbrushing technique (p=0.013) and toothbrushing frequency (p=0.016) are significant contributors to gingival recession. Notwithstanding the limits of a preliminary study, a higher prevalence of buccal recession is observed in the final year students, which have also a significantly lower % of buccal surfaces with calculus (p=0.014). In addition, it clearly appears that there is the necessity to investigate other factors connected with toothbrushing (pressure, time, toothpaste quantity) in order to provide an oral hygiene education without undesired effects.

Use of gloves and prevalence of glove-related reactions in a sample of general dental practitioners in Italy.

OBJECTIVE: The purpose of this study was to evaluate the frequency of the use of gloves and to assess the prevalence of glove-related symptoms in a sample of Italian dentists with a high occupational exposure to latex gloves. METHOD AND MATERIALS: A 31-question instrument was mailed to all dentists (n = 550) practicing in the town of Bologna during 1994 to determine the type of procedures for which gloves were worn by dentists and the prevalence of self-reported glove-related symptoms. RESULTS: Of the dentists who replied to the items (n = 160), 94% reported that they usually wear nonsterile latex examination gloves; and 46% reported that they wear surgical gloves, even if not exclusively. About 98% reported changing gloves after contact with each patient, and 14% reported using disinfectants to treat examination gloves. Of the 106 respondents claiming to use examination gloves for surgical activities, 79 (74%) reported wearing them for extractions. Sterile surgical gloves were reported to be mostly worn for implant placement (47%) and periodontal surgery (42%). There were 46 (29%) responses indicating glove-related problems; of those subjects, 14 (30%) reported having other allergies. CONCLUSION: The use of gloves is common in the sample of Italian dentists, and the choice between nonsterile examination gloves and sterile surgical gloves seems to be made appropriately.

A retentive system for intra-oral fluoride release during orthodontic treatment.

The aim of this study was to test a particular type of intra-oral fluoride releasing device (IFRD), designed to release 0.04 mg/day of fluoride over a period of 6 months, using customized holders, in patients receiving orthodontic treatment. Discomfort, holder detachment, plaque accumulation near the device, and the presence of gingivitis, bleeding, white spot lesions, and/or decay was recorded in 76 orthodontic patients (53 experimental and 23 controls) before and after wearing the device for 12 months. The system proved to be easy and quick to use, and did not cause discomfort. There were no significant differences between the treated and the control groups for plaque index, bleeding, or the presence of gingivitis. In addition, no carious and/or white spot lesions occurred during the duration of this study in the test group.

Plaque removal with variable instrumentation.

The purpose of this study was to evaluate dental plaque removal in a normal healthy mouth, during routine oral hygiene appointments using different techniques and without the use of any disclosing agents. 12 dental hygienists, randomly selected from a continuing education course, were asked to perform oral hygiene on the same patient to remove all the supra-gingival plaque without any time restriction and without the use of a disclosing agents. The plaque index score (O'Leary) was assessed before and after each session with the use of fluorescine and UV light source by an independent examiner. 3 groups of instruments were utilized: group A: ultrasonic scalers + prophy cups; group B: ultrasonic scalers + prophy cups + dental floss; group C: Gracey curettes + prophy cups. While no group was able to remove all the plaque, groups B and C performed significantly better.

Removing high-risk impacted mandibular third molars: a surgical-orthodontic approach.

The authors present a surgical-orthodontic approach to the extraction of impacted mandibular third molars that have a close anatomical relationship between the root and the mandibular canal. They explain that this procedure, in selected cases, decreases the risk of neurological complications and facilitates extraction.

Structural features of latex gloves in dental practice.

The aim of this study was to define from a morpho-structural point of view, using scanning electron microscopy, the features of various types of disposable latex gloves commonly used in Italian dental practice (Biogel D, Trend, Pagni, J&J, Latechnics, Pehasoft, Bantex). None of the brands examined was free from morphological flaws; however, while in some of these only slight depressions were found (Biogel D, Trend), in others (Latechnics, Bantex) there was a marked lack of homogeneity in the latex structure or real holes (Pehasoft). This study emphasizes the current difficulties faced by dentists in the search for safe working conditions.

Atmospheric contamination during dental procedures.

The aim of this study was to evaluate the level of aerosol pollution following dental procedures performed in 15 sessions with an ultrasound scaler and a bicarbonate cleaner. The air contamination was measured by means of the Surface Air System method and the "plate" method (Air Microbial Index). Each colony-forming unit per cubic meter of air was allotted a unit value for statistical analysis. The data were then compared with the hygienic assessments made in previous studies. The results showed that the initial environmental conditions in a dental office initiated at the level of mediocre, then became very bad during dental procedures, and fell between mediocre and very bad at the end of the procedures.

Patient compliance with maintenance therapy in an Italian periodontal practice.

A sample of 414 patients, treated between 1985 and 1988 by an Italian periodontal practice for supportive periodontal therapy, was studied to determine compliance with recommended maintenance programmes. Patients included in the study had attended for supportive periodontal therapy for at least 1 year prior to the close of data collection in 1989. Based on their compliance with the suggested maintenance schedule, patients were classified as complete attending (100% of programmed visits), partial (at least 50% of programmed visits), or insufficient (less than 50% of programmed visits). Only 30% of the initial patient sample was found to be compliant at the end of 1989. Complete compliance decreased as the number of years after active therapy increased, from 38% at 1 year to 20% at 4 years. The % of patients with insufficient compliance increased from 37% to 46% from the 1st to the 2nd year, then remained stable over the following years, indicating that the 1st year represented the critical period when subjects decided whether to follow recommended maintenance therapy. No significant relationships were found between degree of compliance and patient gender, recall schedule or type of treatment procedure performed. However, complete compliant subjects were younger than the other groups (p < 0.03), and compliance increased with the number of surgeries (p < 0.002).

In vitro growth of periodontal fibroblasts on treated cementum.

The aim of the present study was to assess the ability in vitro of phosphoric and citric acids, applied on human root cementum, to neutralize noxious plaque and calculus and to allow the growth of human gingival fibroblasts. Fibroblasts grown on cementum treated with phosphoric acid appeared typically elongated and aligned parallel to the root surface. Fibroblasts grown on cementum treated with citric acid, in both normal and periodontally diseased teeth, lost their elongated shape, acquiring polygonal borders with irregular cytoplasmic extrusions, and the cell density was significantly lower. These findings suggest that phosphoric acid cleaning of both normal and diseased root surfaces may result in an oriented, high rate of fibroblastic growth with more effective periodontal cellular proliferation than that observed after citric acid treatment.