Novel tier 2 service model for complex NHS endodontics.

Aim The use of tier 2 practitioners has been suggested as an intermediate tier in the NHS workforce completing cases of moderate difficulty previously referred to secondary care. Provision of such services varies depending on speciality and local commissioning priorities. This service evaluation investigated reasons for and outcomes of endodontic referrals to an NHS tier 2 service in Powys, Wales.Methods A sample of endodontic referrals was analysed with reasons for referral, referral outcome, requests for consultant support and patient demographic data recorded producing results with frequencies and percentage distributions.Results Of 401 referrals evaluated, common reasons for referral were management of post-treatment disease (56.4%) followed by inability to locate or negotiate root canals (26.9%). Mandibular molar teeth were the most frequently referred. Additionally, 44.1% of patients referred went on to receive treatment. Consultant advice and/or treatment was required in the management of 3.5% of referrals, most frequently relating to referral of traumatic dental injuries, root resorption and immature apices.Conclusions Results demonstrate tier 2 practitioners can effectively manage and treat the majority of NHS endodontic referrals. Remote consultant advice is effective in supporting tier 2 practitioners in the management of complex presentation, allowing effective treatment delivery.

NMR Profiling of Metabolites in Larval and Juvenile Blue Mussels (Mytilus edulis) under Ambient and Low Salinity Conditions.

Blue mussels (Mytilus edulis) are ecologically and economically important marine invertebrates whose populations are at risk from climate change-associated variation in their environment, such as decreased coastal salinity. Blue mussels are osmoconfomers and use components of the metabolome (free amino acids) to help maintain osmotic balance and cellular function during low salinity exposure. However, little is known about the capacity of blue mussels during the planktonic larval stages to regulate metabolites during osmotic stress. Metabolite studies in species such as blue mussels can help improve our understanding of the species' physiology, as well as their capacity to respond to environmental stress. We used 1D ¹H nuclear magnetic resonance (NMR) and 2D total correlation spectroscopy (TOCSY) experiments to describe baseline metabolite pools in larval (veliger and pediveliger stages) and juvenile blue mussels (gill, mantle, and adductor tissues) under ambient conditions and to quantify changes in the abundance of common osmolytes in these stages during low salinity exposure. We found evidence for stage- and tissue-specific differences in the baseline metabolic profiles of blue mussels, which reflect variation in the function and morphology of each larval stage or tissue type of juveniles. These differences impacted the utilization of osmolytes during low salinity exposure, likely stemming from innate physiological variation. This study highlights the importance of foundational metabolomic studies that include multiple tissue types and developmental stages to adequately evaluate organismal responses to stress and better place these findings in a broader physiological context.

Decision-making in the provision of extra-coronal restorations.

UNLABELLED: Decision-making when choosing an extra-coronal restoration for a molar tooth is often multifactorial, requiring consideration for material properties, the underlying tooth tissue, aesthetics and functional requirements. This article reviews the various factors associated with the decision-making when considering an extra-coronal restoration for a molar tooth. The current literature is disseminated and compared to results obtained from clinicians at the Dental Pan Society meeting in 2007. Dentists were seemingly less likely to consider restorations with greater complications for themselves than they were for their patients. The various implications of the results are discussed. CLINICAL RELEVANCE: With the plethora of dental materials available, the clinician has a wide choice of restorations. As clinicians become increasingly aware of the relative complications associated with different restorations, they are less likely to choose those that may result in problems, such as loss of vitality. In comparison, patients, if not kept fully informed, are unlikely to be aware of these problems and therefore may be happy to accept a more 'aesthetic' restoration. This decision dynamic-is examined in this article.

Management of a patient suffering with Cherubism with dental implants.

Cherubism is a rare non-neoplastic, fibro-osseous hereditary disorder characterized by bilateral expansion of the maxilla and mandible producing a characteristic facial appearance. It can affect the facial and dental growth of the individual and often results in gross aesthetic and functional deficiencies. The teeth may also be displaced or submerged and these problems can often compromise successful restorative rehabilitation. This paper describes the restorative management of an adult patient with Cherubism involving a fixed implant retained mandibular restoration. The care utilized 3D planning software and implant insertion guides to facilitate an early loading protocol and the use of optimum bone quality/volume areas.

The use of implants for anchorage in the correction of unilateral crossbites.

The provision of orthodontic anchorage in the adult patient can be compromised due to reduced periodontal support, insufficient number of teeth and limited supra-gingival tooth tissue. Where tooth borne anchorage is unavailable for significant orthodontic movement implants represent a viable alternative. This paper describes the use of dental implants for orthodontic anchorage in a partially dentate patient with a severe unilateral cross-bite where orthognathic surgery was the only other realistic option. The implants were successfully engaged using a composite bridge and a modified quad helix appliance for correction of the malocclusion. Once orthodontics was completed the patient was restored using highly sintered ceramic crowns and bridges. This paper highlights the importance of the multi-disciplinary team and the close liaison between the restorative dentist, orthodontist and technician in treatment planning and provision.

A report on the clinical and radiographic outcomes of 38 cases of apexification with mineral trioxide aggregate.

The aim of the study was to report on the clinical and radiographic assessment of 38 cases of apexification using MTA over a three year period. Thirty-eight cases of immaturely developed teeth requiring endodontic therapy were treated using MTA to achieve an apical barrier prior to obturation with gutta-percha. The teeth were clinically and radiographically assessed. The findings indicate that apexification using MTA is a predictable procedure. In particular, the number of visits and the total time taken to achieve an apical barrier was markedly less than conventional techniques using calcium hydroxide. The presence of a preoperative periapical radiolucency had no effect on the outcome. MTA shows promise as a viable alternative to calcium hydroxide to achieve root-end closure and using MTA, the number of visits to achieve a successful apical barrier may be markedly reduced. The presence of preoperative periapical radiolucencies did not affect the outcome or the treatment protocol.

A prosthetic management technique for osteopetrosis affecting the maxilla.

Bony anatomical anomalies can complicate the construction and successful wearing of removable prostheses. Osteopetrosis is a group of diseases that affect the growth and continuous remodelling of bone which in turn can result in gross irregular alveolar bone morphology. This paper describes the management of a patient with this problem and emphasises the challenges in constructing a successful complete maxillary removable prosthesis. The utilisation of a flexible base plate material as an alternative to traditional materials will be highlighted. Irregular bony morphology is a recognised potential obstacle to the successful construction of removable prostheses. In most cases the problem can be overcome but in extreme and less common circumstances, management of these features can be more problematic. This paper describes a technique used to manage extreme alveolar irregularity which may perhaps be applied to those problems more commonly encountered in every day clinical practice but are less extreme then those described in this paper.

Modern restorative management of patients with congenitally missing teeth: 4. The role of implants.

UNLABELLED: In this fourth and final paper on the management of patients with congenitally missing teeth, the use of dental implants is considered. This group of patients often provides unique challenges when implant reconstruction is considered. Often a multidisciplinary approach is required involving orthodontists, oral surgeons and restorative dentists. The use of dental implant systems is a rapidly developing area of dentistry and its implications on hypodontia are discussed. This paper identifies the problems associated with a congenital absence of teeth and addresses their management in relation to the use of implants. CLINICAL RELEVANCE: The use of dental implants in hypodontia patients should always be considered as a treatment option. These groups of patients, however, require careful planning, often of a multidisciplinary nature, so that the timing of the various treatment modalities is seamless.

Modern restorative management of patients with congenitally missing teeth: 3. Conventional restorative options and considerations.

Restoration of spaces in hypodontia patients needs to take into account many factors including, the number of missing teeth, the distribution of space, the size of the teeth, and the age of the patient. This paper considers adhesive and conventional bridgework, as well as removal alternatives for the restoration of spaces. The various merits of each are discussed, together with treatment planning considerations for such cases.

Modern restorative management of patients with congenitally missing teeth: 1. Introduction, terminology and epidemiology.

The management of patients with congenitally missing teeth can be a challenge and, in many cases, requires multidisciplinary care. In this four-part series, a contemporary approach to managing this group of patients is discussed. This first paper examines the terminology, epidemiology and restorative challenges that such patients can exhibit.

Cleidocranial dysplasia--a late diagnosis.

UNLABELLED: Cleidocranial dysplasia is a rare congenital disorder of bone characterized by abnormalities of clavicle, skull and dentition. There are features which are pathognomic for this condition and diagnosis can usually be made early in life. This report presents a case that was diagnosed very late in life, with a resultant compromised dental state, and discusses current treatment modalities and the differential diagnosis with another condition with which this was mistaken. CLINICAL RELEVANCE: Delayed eruption of permanent teeth must be diagnosed and investigated early so that it can be managed appropriately.

Modern restorative management of patients with congenitally missing teeth: 2. Orthodontic and restorative considerations.

Managing edentulous spaces in patients with congenitally missing teeth demands careful planning and, often, a multidisciplinary approach. Orthodontic tooth movement can be considered to close spaces as well as improve the distribution of available teeth. In this second paper, the advantages of a collaborative approach are discussed.