EUROPEAN SOCIETY OF ENDODONTOLOGY Undergraduate Curriculum Guidelines for Endodontology.

Undergraduate education should accomplish graduates who are skilled to provide quality care for patients, who are aware of their scope of practice, competency level and limits and who are open to referring patients whose needs are beyond their own skills and experience. They should also become self-efficacious. Quality performance begins with good diagnosis and decision-making. Graduates should understand when to treat, why to treat, what to treat and how to treat. These guidelines include a list of capabilities that the graduating student will be expected to have achieved to provide a minimum level of competency in endodontics. Theoretical knowledge, practical skills, understanding and insight should be assessed, with both formative and summative assessment procedures, making use of reflection and feedback. Endodontic procedures should be undertaken within the context of comprehensive patient care and should be evidence based. Students should not perform treatments on patients until they have demonstrated in a pre-clinical setting that they possess the required skills. Only if it is not possible to simulate a specific procedure sufficiently in a pre-clinical setting should students learn this procedure by performing it clinically under close supervision. Clinical endodontics should ideally be supervised by endodontists or by staff with special knowledge, interest and self-efficacy in endodontics. It is advised to ensure that students apply their knowledge and practice their skills periodically throughout the continuum of endodontic education until graduation. A philosophy of lifelong learning and evidence-based practice should be instilled in all dental undergraduates.

Disordered eating behaviors in pediatric patients with inflammatory bowel disease in remission or mild-moderate disease activity.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder that affects the gastrointestinal tract. Disordered eating describes irregular eating behaviors that may be a precursor to an eating disorder diagnosis. Higher rates of disordered eating have been described in chronic diseases. Screening for disordered eating is not performed in pediatric patients with IBD. The goal of this longitudinal study was to use the Eating Attitudes Test (EAT-26) to screen pediatric patients with IBD for disordered eating, estimate our population's prevalence, identify potential risk factors, and correlate positive EAT-26 screen results with evaluation in adolescent medicine clinic. METHODS: Eighty patients with IBD between 10 and 21 years completed the EAT-26 questionnaire during gastroenterology clinic visit. Disease activity was measured using Pediatric Ulcerative Colitis Activity Index (PUCAI) and Pediatric Crohn's Disease Activity Index (PCDAI). Patients also rated their own disease activity on a numerical scale. RESULTS: Five patients had a positive EAT-26 screen and were evaluated in the adolescent medicine clinic. One hundred percent of those who screened positive were diagnosed with a concomitant eating disorder once evaluated. Only 20% of those who screened positive had active IBD. Higher weight, body mass index, and patient perception of disease activity were associated with increased EAT-26 score. CONCLUSION: Pediatric patients with IBD are at risk for disordered eating, with a prevalence of 6% in our population, which is twice the prevalence of disordered eating in the general population. The EAT-26 questionnaire is a feasible tool to screen pediatric IBD patients for disordered eating.

The use of medicaments in the management of symptomatic irreversible pulpitis: A community-based cohort study.

AIM: To investigate patient outcomes from either pulpotomy or pulpectomy for the management of symptomatic irreversible pulpitis, with and without application of antibiotic/corticosteroid pastes in urgent primary dental care settings in the United Kingdom. METHODOLOGY: All patients receiving intervention for symptomatic irreversible pulpitis in three different primary care settings were invited to participate. Pre-operatively, data regarding patients' numerical ratings scale (NRS), pain score (0-10), analgesic use, oral-health impact profile-14 (OHIP-14) and need for time away from work were collected. For 7 days post-operatively, participants recorded their NRS pain score, global rating of change score, medication use and their ability to work. Analysis used a mixed-effects model with post hoc Tukey's multiple comparisons test for continuous data and chi-squared or Fisher's exact test for categorical data. To test the effect of the corticosteroid/antibiotic paste, pulpectomy and pulpotomy groups were combined following Mantel-Haenszel stratified analysis or a weighted average of the difference between pulpotomy and pulpectomy with and without the use of corticosteroid/antibiotic paste. A binary composite score was constructed using pre- and post-operative data, whereby overall treatment success was defined as: (i) patients did not return for treatment due to pain by day seven; (ii) at day three, there was a 33% (or 2-points) reduction in NRS pain score; (iii) there was a change score of +3 in global rating; (iv) the patient was no longer using analgesia and able to return to work. RESULTS: Eighty-five participants were recruited, with 83 completing follow up. Overall treatment success was 57%, with 25% of participants returning for more treatment due to inadequate pain relief. Overall treatment success did not differ between the two groups (p = .645), although patients self-reported greater improvement with an antibiotic/corticosteroid dressing for global rating of change (p = .015). CONCLUSIONS: This study identified limited evidence of improved outcomes using antibiotic/corticosteroid dressings in the management of symptomatic irreversible pulpitis in the emergency setting. Further clinical research is needed to understand if these medications are beneficial in affording pain relief, above that of simple excision of irreversibly inflamed pulp tissue.

Weekly Folic Acid Is a Convenient and Well-Tolerated Alternative to Daily Dosing in Pediatric Patients with Inflammatory Bowel Disease on Methotrexate.

BACKGROUND: Inflammatory bowel disease (IBD) is a chronic autoimmune disorder that affects the gastrointestinal tract. Methotrexate is a folate analog immunosuppressant used in the management of pediatric IBD. Daily folic acid supplementation is currently recommended to prevent folate deficiency and reduce the side effects of methotrexate such as nausea, stomatitis, and hepatotoxicity. The aim of this study was to evaluate the safety and adequacy of once-weekly folic acid supplementation in pediatric inflammatory bowel disease patients taking methotrexate. METHODS: In this single-arm observational study, we included subjects aged 2-21 years old with inflammatory bowel disease who were receiving a standard oral methotrexate dose of 10-15 mg/m2 weekly and 800 mcg of folic acid daily. Baseline folate level, blood counts and chemistries, and a symptom questionnaire were completed. Subjects were switched to weekly 800 mcg of folic acid to be taken in conjunction with methotrexate. Monthly phone calls with a standardized questionnaire were used to assess compliance and any change in symptoms. Follow-up blood tests were obtained 6 months after enrollment. Normal folate level was defined as >5.38 ng/mL. RESULTS: Thirty-one subjects were enrolled. Five subjects were withdrawn due to poor compliance or transition to adult gastroenterology. Twenty-one (81%) subjects had Crohn's disease (17 with ileal involvement) and five (19%) had ulcerative colitis. Twelve (39%) subjects were on methotrexate as a combination therapy with a biologic agent. At the 6-month follow-up visit, all subjects had stable folic acid levels (>5.38 µg/L) without macrocytic anemia. Monthly questionnaires found no increased symptoms, and there were no adverse events. CONCLUSIONS: Once weekly folic acid supplementation at a dose commonly found in a multivitamin may be sufficient to maintain normal folate levels without the development of adverse symptoms in pediatric patients with inflammatory bowel disease on methotrexate therapy.

The financial and quality of life impact of urgent dental presentations: A cross-sectional study.

AIM: This study aimed to: (i) calculate personal financial costs associated with urgent dental attendance; and (ii) investigate the pain-related disability and quality of life impact of dental conditions which result in urgent dental attendance. METHODOLOGY: Data were collected from those presenting with urgent dental conditions to an out-of-hours dental service, a dental emergency clinic (DEC) and five primary care general dental practices across North-East England. A pre-operative questionnaire explored the impact of urgent dental conditions on oral health-related quality of life (OHRQoL) using Oral Health Impact Profile-14 (OHIP-14) and a modified Graded Chronic Pain Scale (GCPS). OHIP-14 yields a maximum score of 56, with a higher score indicating a lower OHRQoL. Personal financial costs were summed to provide a total. These included travel, appointment fees, childcare costs, medication use and time away from work. Data were analysed using one-way anova and multivariable modelling. RESULTS: In total, 714 participants were recruited. The mean OHIP-14 score was 25.73; 95% CI [24.67, 26.79], GCPS CPI was 71.69; 95% CI [70.09, 73.28] and GCPS interference was 49.56; 95% CI [47.24, 51.87]. Symptomatic irreversible pulpitis was the most frequently managed dental emergency and was associated with the highest mean OHIP-14 score (31.67; 95% CI [30.20, 33.15]). The mean personal financial cost of urgent dental care (UDC) was £85.81; 95% CI [73.29, 98.33]. Differences in travel time (F[2, 691] = 10.24, p < .001), transport costs (F[2, 698] = 4.92, p = .004), and appointment time (F[2, 74] = 9.40, p < .001) were significant between patients attending an out-of-hours dental service, DEC and dental practices for emergency care, with a DEC being associated with the highest costs and dental practices the lowest. CONCLUSIONS: Diseases of the pulp and associated periapical disease were the most common reason for patients to present for UDC and were the most impactful in terms of OHRQoL and pain in the present sample. Personal financial costs are significant from urgent dental conditions, with centralized services increasing the burden to patients of attending appointments.

Factors that influence the outcome of pulpotomy in permanent teeth.

The promotion of minimally invasive treatments focussed on the maintenance of pulp vitality has become a priority area in Endodontics. These vital pulp treatments (VPT) include partial and full pulpotomy, during which diseased coronal pulp tissue is removed prior to placement of a capping biomaterial and restoration. Traditionally, pulpotomies were confined to the treatment of carious primary and traumatized permanent teeth. However, these treatments have now been proposed as definitive solutions for cariously exposed permanent teeth with mild symptoms or even symptoms indicative of irreversible disease. Until recently, it was recommended that carious exposure of mature permanent teeth be managed by root canal treatment. The promotion of pulpotomy as an alternative treatment has opened up a wave of laboratory and clinical research aimed at improving therapies or evaluating clinical outcomes. In modern evidence-based endodontics, it is imperative that the outcomes of both partial and full pulpotomy are considered and important prognostic factors identified, so that improvements can be made to aid clinical decision-making and to direct new research. In this narrative review, the outcomes of partial and full pulpotomy are discussed, before analysis of patient, intraoperative and postoperative factors that influence the outcome of the pulpotomy procedure. The review highlights that although partial and full pulpotomy for the treatment of even pulpal disease are highly successful procedures, this is based on low-quality evidence with a lack of prospective, comparative trials investigating potential prognostic factors. Based on current evidence, it appears that age, gender, tooth type, root development and intraoperative pulpal haemorrhage do not impact significantly on pulpotomy outcome, whilst others such as caries depth, inflammatory status of the pulp, capping material, level of inflammatory pulpal-biomarkers and the final restoration integrity do. Other factors, including the influence of exposure type, periodontal condition, pulpal lavage, magnification, operator experience, isolation of the operating field and type of pulpotomy, require further experimental investigation before definitive conclusions can be made relating to the success of the pulpotomy procedure. Finally, there is not only a need for future well-designed prospective research addressing these issues but also a widening of our understanding of outcome to include patient-reported as well as clinician-reported outcomes.

Treatment of cracked teeth: A comprehensive narrative review.

OBJECTIVES: The term "cracked tooth" is used to describe an incomplete fracture initiated from the crown and progressing towards a subgingival direction. Despite the high prevalence of cracked teeth and their frequent association with symptoms and pulpal or periapical pathoses, there is still no consensus in the literature with regard to their restorative and endodontic management. Therefore, the aim of this narrative review was to evaluate the most relevant research and provide an up-to-date comprehensive overview regarding the treatment of cracked teeth. MATERIALS AND METHODS: An electronic literature search was carried out in MEDLINE (via Ovid), Embase (via Ovid), Scopus, and Web of Science as well as several "Grey literature" sources up to February 22nd 2022 using a combination of pre-specified 'free-text' terms (keywords) and "subject headings." The search process was supplemented by handsearching in relevant dental journals and reference lists. This narrative review focused on clinical follow-up studies (observational or interventional studies, case series/reports), laboratory studies and systematic reviews written in English language that reported data on treatment of permanent cracked teeth. The selection of relevant studies was carried out by two reviewers (AK and DG) working independently in two consecutive stages: title/abstract screening and full-text retrieval. Any discrepancies in the study selection were resolved by discussion between the reviewers. RESULTS: In total, 64 articles were selected for inclusion in this narrative review. CONCLUSIONS: Cracked teeth with normal pulp or reversible pulpitis have exhibited high pulp and tooth survival rates by the provision of direct or indirect composite restorations. Besides, recent data favour monitoring, especially in the absence of symptoms or compromised tooth structure. When endodontic intervention is required, current evidence suggests that along with appropriate restorative management, outcomes of cracked teeth may be comparable to those of non-cracked root filled teeth.

Does an interim dressing with calcium hydroxide reduce endotoxins between endodontic appointments?

Data sources PubMed, Cochrane Library, LILACS/Biblioteca Brasileira de Odontologica, Web of Science, Embase, Scopus, grey literature.Study selection Randomised and non-randomised clinical studies, experimental studies. Population: human studies with permanent dentition; Intervention: evaluation of lipopolysaccharide (LPS) after dressing with calcium hydroxide (CH); Comparison: evaluation of LPS before dressing with CH; Outcome: antimicrobial efficacy against LPS.Data extraction and synthesis A modified Cochrane Risk of Bias (RoB) tool was used to evaluate internal validity of randomised controlled trials, Robins-1 tool for non-randomised controlled trials, and the 'Before and After' tool for experimental studies. Meta-analyses were conducted by subgrouping according to CH use, chemo-mechanical preparation (CMP), antimicrobial substance (AS), and irrigant. Further analyses explored incidence of LPS reduction. All subgroups were assessed for heterogeneity through I2 test and the random-effect model was applied. Sensitivity analysis was performed to evaluate the influence of studies with RoB in effect significance.Results Nine studies were included for qualitative assessment, of which seven were included for meta-analysis. Three studies were assessed as low RoB, one was medium risk, with two having a high RoB. Three studies presented with 'some concerns'. After dressing with CH, no AS resulted in 61.7% of teeth with reduction in LPS (95% CI: 37.7%-82.9%, I2 = 96.7%), compared to AS where 98.9% of teeth showed an LPS reduction (95% CI: 97.4%-99.8%, I2 = 38.6%). Where mean reductions in LPS were compared, CH with or without AS, reduced mean LPSs before (standardised mean difference [SMD] = 21.087 [CI: 21.453 to 20.721], P = 0.001, I2 = 58.7%) and after CMP (SMD = 20.919 [CI: 21.156 to 20.682], P = 0.001, I2 = 24.7%) using a CH dressing. Considering the irrigant solutions, the overall results showed a reduction before (SMD = 21.053 [CI: 21.311 to 20.795], P = 0.001, I2 = 58.7%) and after CMP (SMD = 20.938 [CI: 21.147 to 20.729], P = 0.001, I2 = 24.6%) using a CH dressing. There was a reduction in mean LPS over time, up to 30 days. All analyses presented a very low certainty of evidence.Conclusions An interim dressing with CH reduces LPS levels below those achieved with CMP and AS, but does not eliminate LPS completely. No evidence is presented on improved clinical outcomes following multiple-visit treatment with CH dressing.

Examining Risk Factors of Health-Related Quality of Life Impairments Among Adolescents with Inflammatory Bowel Disease.

Inflammatory Bowel Disease (IBD) is a chronic, costly, and burdensome disease that is typically diagnosed during adolescence. Despite the use of effective treatments, rates of relapse and intestinal inflammation remain high and put patients at risk for long term physical and psychosocial health complications. Given the costs associated with IBD, it is critical to examine potential risk factors of poor health-related quality of life (HRQoL) among patients for the enhancement and further development of interventions. As such, the aim of the current study was to examine how sociodemographic and disease characteristics, psychosocial problems, and adherence behaviors impact HRQoL among a sample of youth with IBD. 107 adolescents with IBD and their caregiver completed self- and parent-report measures as part of a psychosocial screening service. Medical records were reviewed to obtain information regarding diagnosis, insurance, medication use, illness severity, and disease activity. Results revealed lower HRQoL scores among adolescents with more psychosocial problems (Est. = -3.08; p < .001), greater disease severity (Est. = -.40; p = .001), and those who identified as Black (Est. = -.38; p < .05). Greater disease severity (Est. = .13 p = .004), use of nonpublic insurance (Est. = .32 p = .004), and fewer psychosocial problems (Est. = -.13 p = .04) were associated with greater adherence behaviors. These findings suggest that implementing individually tailored, evidence-based psychological interventions focused on coping with psychosocial problems and symptoms may be important in enhancing adherence behaviors and HRQoL among adolescents with IBD.

Cytomegalovirus in pediatric inflammatory bowel disease patients with acute severe colitis.

BACKGROUND: The prevalence and significance of cytomegalovirus (CMV) colitis in pediatric acute severe colitis is unknown. The aim of this study was to determine the prevalence of CMV in colonic mucosa of children with acute severe refractory colitis and compare the clinical characteristics and outcomes of CMV positive and negative patients. METHODS: In a case-control study, colonic biopsy specimens from children with severe refractory colitis were tested for CMV, and matched with non-refractory IBD controls. We characterized CMV positive patients by assessing laboratory values, concurrent medications, and need for surgery as compared with CMV negative refractory colitis patients. RESULTS: Colonic biopsies from 96 patients were evaluated for CMV; 48 with severe refractory colitis, and 48 non-refractory controls. There was an increased prevalence of CMV in severe refractory colitis [7/48 (14.6%), P < 0.0001]; all were previously CMV negative. Viral DNA burden on immunohistochemistry was not predictive of response to antiviral therapy or need for surgery at 12 months. Lymphopenia was seen in all CMV positive patients, but this did not demonstrate statistical significance (P = 0.09). We did not see an association between azathioprine or infliximab use and the need for surgery at 12 months. CONCLUSIONS: There is an increased prevalence of CMV in colonic biopsies of pediatric patients with severe refractory colitis. Viral burden does not predict clinical outcomes or subsequent need for colectomy.

Pneumococcal Polysaccharide Vaccination in Pediatric Inflammatory Bowel Disease.

According to current recommendations, in addition to 13-valent pneumococcal conjugate vaccine (PCV13) series, all children with inflammatory bowel disease (IBD) aged ≥2 years, with planned or current immunosuppression, should receive pneumococcal polysaccharide vaccine (PPSV23). The primary aim was to determine the PPSV23 immunization rates in our pediatric IBD patients. The secondary aim was to determine the incidence of invasive pneumococcal disease in these patients. The IBD database at Le Bonheur Children's Hospital was retrospectively reviewed to identify all cases diagnosed from 2003 to 2015. Out of 190 IBD patients, 106 on immunosuppressive drugs, whose immunization records could be obtained from the state database, were included in the study. Medical records were reviewed to determine infections seen in these patients from the time of diagnosis to date. IBD patients in our study ranged from age 2 to 18 years. Only 4 of 106 (3.7%) patients had received PPSV23 vaccine. Only 1 patient (0.9%) had probable pneumococcal disease and none with invasive pneumococcal disease. Clostridium difficile (11 patients) and Cytomegalovirus colitis (4 patients) were more commonly encountered. All our patients received the recommended PCV13 vaccine. The majority of our pediatric IBD patients did not receive PPSV23 vaccine. Fortunately, we did not see a high rate of invasive pneumococcal disease in our patients suggesting that they may be protected by the primary PCV13 vaccine series. Non-pneumococcal infections were more common in this population.

A randomized, double-blinded, placebo-controlled study of the use of viscous oral cromolyn sodium for the treatment of eosinophilic esophagitis.

BACKGROUND: There is a need for effective, nonsteroid pharmacologic therapies for eosinophilic esophagitis (EoE). Cromolyn sodium offers an option because mast cells have been implicated in the symptomatology of EoE and cromolyn has been shown to have some anti-eosinophilic properties. OBJECTIVE: To evaluate the efficacy of cromolyn in decreasing esophageal eosinophilia in patients with EoE. Secondary outcomes included symptom improvement and adverse effects. METHODS: We conducted a randomized, double-blinded, placebo-controlled trial of viscous oral cromolyn for EoE in pediatric patients. Subjects were randomized to 100 mg (2-11 years of age) or 200 mg (12-17 years of age) of cromolyn or placebo 4 times daily. The medications were mixed with powdered sugar at home to make them viscous. RESULTS: Sixteen subjects (50% boys, median age 11.4 years) were enrolled. Nine were randomized to cromolyn and 7 were randomized to placebo. Cromolyn decreased the peak eosinophil count from 62.1 to 57.3 eosinophils per high-powered field (P = .78) and placebo decreased the peak eosinophil count from 87.0 to 71.3 eosinophils per high-powered field (P = .62) One subject randomized to cromolyn and none in the placebo arm had complete resolution of eosinophilia. Cromolyn decreased symptoms scores from a mean baseline score of 37.8 to a mean post-therapy score of 17.5, which was a 54% decrease (P = .04). Placebo decreased the symptom scores from a baseline score of 32.2 to a post-therapy score of 23.3, which was a 28% decrease (P = .05). CONCLUSION: Cromolyn, when mixed into a viscous preparation, did not significantly decrease esophageal eosinophilia. However, it did decrease symptom scores (although not significantly more than placebo) and led to complete resolution in 1 subject.

Graduation Day: Healthcare Transition From Pediatric to Adult.

Because more patients with pediatric-onset chronic conditions are surviving into adulthood, they are graduating from pediatric healthcare to self-management and adult healthcare. This transfer of care needs to be a process of transitioning medical and nutrition care. Despite having position statements from professional organizations and several proposed models, issues in the transition process have been well described, and gaps in transition care persist. Healthcare providers need to be aware of special needs of emerging adults related to education on chronic condition and self-management skills, emotional support before and after transition, and legal rights for both the patient and the parent if the emerging adult is not developmentally appropriate to make his or her own healthcare decisions. Both pediatric and adult providers need to be in active communication with each other and the patient to develop trusting relationships and actively support the transition of care. This review of literature describes several models for transitioning, measureable outcomes, insurance provider issues, and legal issues pertaining to healthcare transition.

Effect of topical neuromodulatory medications on oral and skin keratinocytes.

BACKGROUND: Neuromodulatory medications (NMs), such as amitriptyline, carbamazepine and gabapentin, are used as topical preparations for the management of neuropathic orofacial pain (NOP) and have produced promising preliminary results. The aim of this study was to investigate the effects of three aforementioned NMs on cell lines relevant to the orofacial tissues in vitro as no published studies have examined the effect of these topical NMs. METHODS: Cellular viability was measured using alamarBlue® , testing cumulative and specific time point effects of NMs on human skin keratinocytes and oral keratinocytes. Effects of the NMs on cell counts were investigated by CCK-8 assay. Drug concentrations released from NM orabase pastes after 30-min incubation were measured by high-performance liquid chromatography. Using these clinical concentrations, morphological changes and cytokine expression were investigated using scanning electron microscopy (SEM) and human inflammatory antibody array (AAH), respectively. RESULTS: Cumulative and specific time point viability and cell count methods revealed that amitriptyline caused a significant decrease in cellular viability and counts in both cell lines. Carbamazepine also had significant effects after long-term exposure and at higher concentrations, whilst gabapentin had little demonstrable effect. SEM confirmed the cytotoxicity of amitriptyline, whilst AAH revealed no significant changes in cytokine expression following amitriptyline, carbamazepine or gabapentin exposure compared with control. CONCLUSIONS: The results raise concerns about the safety of topical amitriptyline as it was cytotoxic to skin and oral keratinocytes in both exposure times and concentrations, whilst carbamazepine was cytotoxic only at high concentrations and after longer exposure times and gabapentin had no demonstrable effects.

Response of Blue Rubber Bleb Nevus Syndrome to Sirolimus Treatment.

BACKGROUND: Blue rubber bleb nevus syndrome (BRBNS) is a rare multifocal venous malformation syndrome involving predominantly the skin and gastrointestinal tract. Traditional treatment modalities include corticosteroids, interferon-α, sclerotherapy, and aggressive surgical resection. Sirolimus has been used in several single case reports. PROCEDURE: We performed a single-institution retrospective review of four children with BRBNS, who received sirolimus as part of their treatment regimens. A diagnosis of BRBNS was based on clinical, radiologic, and pathologic criteria. RESULTS: Median age was 6.5 years (range: 2-16 years). Pathologic evaluations revealed a combined malformation with venous and lymphatic components. The novel finding of a lymphatic component was confirmed with PROX-1 immunostaining. Patients received oral sirolimus with target drug levels between 10 and 13 ng/ml. Responses to treatment were defined as stabilization/decrease in size of lesions; resolution of transfusion requirements; reduction in pain, and improvement in quality of life (QOL). Median time to response was 1.5 months (SD ± 0.96 month, range: 1-3 months). Median follow-up was 21 months (range: 18-26 months). Lesion size and characteristics improved in all patients. All patients reported decrease in pain and improvement in QOL. All three patients requiring transfusions became transfusion-independent. One patient had resolution of coagulopathy. Adverse effects of sirolimus consisted of mucositis in three patients and neutropenia in one patient. CONCLUSIONS: Sirolimus is safe and efficient for the treatment of BRBNS. Further prospective studies are needed to evaluate the long-term effectiveness of this drug. This is the first report that identifies a lymphatic component as part of BRBNS.

Determination of the mental foramen position in dental radiographs in 18-30 year olds.

OBJECTIVES: To determine the radiographic position and reliability of assessing mental foramen (MF) position in relation to premolar crowns in an 18- to 30-year-old UK-based population. METHODS: Following ethical approval and a power calculation, the position of the MF was recorded in relation to premolar crowns and apices in 100 dental panoramic tomographs. Positions were assessed by three senior clinicians independently, then by consensus. Data were analysed using descriptive statistics, χ(2) and Fleiss' and Cohen's kappa. RESULTS: Reliability data showed only fair to moderate agreement on independent scoring. Substantial to almost perfect agreement was achieved by consensus, demonstrating the most common position for the MF to be between the first and second premolar teeth when using both premolar crowns (51%) and apices (76%) as reference points. There was a significant difference in the position of the foramen between the left and right sides (p < 0.05), with only 62% of cases showing symmetry. CONCLUSIONS: The most common position for the MF is between the first and second premolar teeth; however, anatomical variation is seen. Use of pre-operative radiographs to relate the position of the MF to premolar crowns may not be reliable.

Factors affecting patient valuations of caries prevention: Using and validating the willingness to pay method.

OBJECTIVES: Determining the value of, or strength of preference for health care interventions is useful for policy makers in planning health care services. Willingness to pay (WTP) is an established economic technique to determine the strength of preferences for interventions by eliciting monetary valuations from individuals in hypothetical situations. The objective of this study was to elicit WTP values for a dental preventive intervention and to analyze the factors affecting these as well as investigating the validity of the WTP method. METHODS: Patients aged 40 years plus attending dental practices in the UK and Germany were recruited on a consecutive basis over one month. Participants received information about a novel root caries prevention intervention. They then completed a questionnaire including a WTP task. Where the coating was indicated, patients were offered this for a payment and acceptance was recorded. Analysis included econometric modelling and comparison of expected (based on stated WTP) versus actual behaviour. RESULTS: The mean WTP for the coating was £96.41 (standard deviation 60.61). Econometric models showed that no demographic or dental history factors were significant predictors of WTP. 63% of the sample behaved as expected when using stated WTP to predict whether they would buy the coating. The remainder were split almost equally between those expected to pay but who did not and those who were expected to refuse but paid. CONCLUSIONS: Values for a caries preventive intervention had a large and unpredictable variance. In comparing hypothetical versus real preferences both under- and over-valuation occurs. CLINICAL SIGNIFICANCE: Wide and unpredictable variation in valuations for prevention may mean that there are difficult policy questions around what resource should be allocated to dental prevention and how to target this resource.

Biodentine and mineral trioxide aggregate induce similar cellular responses in a fibroblast cell line.

INTRODUCTION: The aim of this study was to assess the cell viability and messenger RNA expression of interleukin (IL)-1α and IL-6 in 3T3 fibroblast cells when in direct contact with Biodentine (Septodont, Saint Maur de Fossés, France) and mineral trioxide aggregate (MTA). METHODS: Biodentine and MTA were coated onto coverslips and allowed to set. An uncoated coverslip and one coated with GC Fuji IX (GC Corporation, Tokyo, Japan) were used as controls. Coverslips were cultured with 3T3 fibroblast cells. Cell viability was assessed quantitatively using AlamarBlue dye (Serotec, Oxford, UK) after 3, 6, 24, and 72 hours. Morphologic cell changes of 3T3 cells in contact with BD and MTA were observed by scanning electron microscopy, and cytokine expression was assessed at the messenger RNA level by semiquantitative reverse-transcription polymerase chain reaction after 3 and 24 hours of direct contact with the materials. RESULTS: Cells in contact with Biodentine and MTA showed similar viability to untreated control cells at all time points, with the exception of 6 hours when viability was decreased with both treatments. Examination by scanning electron microscopy revealed cells adhering to most of the Biodentine surface after 24 hours. However, for MTA samples, significantly fewer cells were observed. The messenger RNA expression of IL-1α and IL-6 by cells in contact with Biodentine was similar to cells in contact with MTA. CONCLUSIONS: Biodentine and MTA showed similar cytotoxicity and induced a similar pattern of cytokine expression.

Is mandibular molar buccal infiltration a mental and incisive nerve block? A randomized controlled trial.

INTRODUCTION: The aim of this study was to compare the efficacies of buccal local anesthetic infiltrations at various sites of the mandible in order to elucidate the mechanism of action of articaine mandibular infiltrations. METHODS: After a power calculation and ethical approval, 22 volunteers received 1.8 mL 4% articaine hydrochloride with 1:100,000 adrenaline as a buccal infiltration at the canine, first, or second molar in a randomized, double-blind, crossover design. The injections at the canine and first molar were considered equidistant from the mental foramen. Responses of the first and second molars, first premolar, and lateral and central incisors were assessed using an electronic pulp tester over a 47-minute period. Volunteers were asked to rate the discomfort of each injection using a visual analog scale. Data were analyzed using repeated measures analysis, McNemar, and Mann-Whitney U testing. RESULTS: Injections at the canine and first molar teeth produced anesthesia in all teeth tested in some volunteers. There was no significant difference between anesthetic success of the first premolar after infiltration at the canine or the first molar. Injection at the second molar failed to produce anesthesia of the incisor teeth. Anesthesia was significantly more likely after injections at an adjacent site. There was no difference in discomfort associated with injections at different sites of the mandible. CONCLUSIONS: Articaine first mandibular molar infiltrations achieve an effect via a combination of modified mental and incisive nerve block and local infiltration. Infiltration at the second molar produces anesthesia of both molar and premolar teeth, primarily via infiltration.