What is the best long-term treatment modality for immature permanent teeth with pulp necrosis and apical periodontitis?

PURPOSE: To evaluate and assess the current knowledge about apexification and regenerative techniques as a meaningful treatment modality and to map the scientific evidence for the efficacy of both methods for the management of traumatised immature teeth with pulp necrosis and apical periodontitis. METHODS: This systematic review searched five databases: PubMed, Web of Science, Cochrane Library, Ovid (Medline), and Embase. Published articles written in English were considered for inclusion. The following keywords were used: Regenerative endodontic treatment OR regenerat* OR revital* OR endodontic regeneration OR regenerative endodontics OR pulp revascularization OR revasculari* OR 'traumatized immature teeth'. Only peer-reviewed studies with a study size of at least 20 cases followed up for 24 months were included. Eligibility assessment was performed independently in a blinded manner by three reviewers and disagreements were resolved by consensus. Subgroup analyses were performed on three clinical outcomes: survival, success, and continued root development. RESULTS: Seven full texts out of 1359 citations were included and conventional content analysis was performed. Most of the identified citations were case reports and case series. CONCLUSIONS: In the present systematic review, the qualitative analysis revealed that both regenerative and apexification techniques had equal rates of success and survival and proved to be effective in the treatment of immature necrotic permanent teeth. Endodontic regenerative techniques appear to be superior to apexification techniques in terms of stimulation of root maturation, i.e. root wall thickening and root lengthening. Knowledge gaps were identified regarding the treatment and follow-up protocols for both techniques.

Dental treatment and caries prevention preceding treatment under general anaesthesia in healthy children and adolescents: a retrospective cohort study.

AIM: This was to examine healthy children and adolescents treated under general anaesthesia (GA) and a matched control group not receiving GA to compare treatment and preventive care received prior to GA treatment. METHODS: This retrospective cohort study included 71 healthy subjects and 213 age- and gender-matched control subjects. The treatment group had been consecutively referred from the Public Dental Health Service (PDS) in Stockholm to the Department of Paediatric Dentistry, Eastman Institute, Stockholm during 2006-2007. Data was extracted from the patient records at the PDS, including variables such as number of dental visits, treatment/prophylaxis prior to GA, number of missed and cancelled appointments, and number of decayed teeth. RESULTS: On average, the treatment group had significantly more decayed teeth (p < 0.001) than the control group. Furthermore, the treatment group had significantly more restorations (p < 0.01), had visited the dentist significantly more often (p < 0.001), and had undergone significantly more behaviour management treatment and preventive treatment (p < 0.001). In the treatment group 65% of the children and adolescents, had received no behaviour management treatment and 48%, no preventive treatment. CONCLUSIONS: In the Stockholm PDS, over half of the children and adolescents referred by general dentists to paediatric specialists had no behaviour management treatment and nearly half, no preventive treatment, despite receiving significantly more operative treatment compared with matched controls. General dentists should target high caries-risk patients for additional behaviour management and preventive care to reduce the need for treatment under GA.

The relationship between matrix metalloproteinases (MMP-3, -8, -9) in serum and peripheral lymphocytes (CD8+ , CD56+ ) in Down syndrome children with gingivitis.

BACKGROUND AND OBJECTIVE: Altered immune response may be a major contributor to periodontal disease in Down syndrome. This study investigated the relationship between peripheral lymphocytes and matrix metalloproteinases (MMPs) in serum in Down syndrome children with gingivitis. MATERIAL AND METHODS: Children with Down syndrome (n = 10) and healthy controls (n = 10) were clinically and radiographically examined during dental treatment under general anaesthesia. Peripheral blood and gingival crevicular fluid were collected from each subject and concentrations were determined: serum MMP-2, -3, -8 and -9; serum tissue inhibitors of metalloproteinases (TIMP) -1, -2 and -3; and gingival crevicular fluid. Leukocytes were isolated from peripheral blood and the relative amounts (%) of the various cell phenotypes were analysed using flow cytometry. In addition, peripheral blood cells were treated with Porphyromonas gingivalis lipopolysaccharide and levels of MMPs and TIMPs measured. RESULTS: Concentrations of MMP-3, MMP-8 and TIMP-1 in serum were significantly higher (p < 0.05) in the Down syndrome group compared to the controls. When peripheral blood leukocytes were cultured in the presence or absence of P. gingivalis lipopolysaccharide, MMP-8 levels were significantly (p < 0.05) higher in the Down syndrome group compared to controls. Children with Down syndrome exhibited significant positive correlations between CD8(+) T cells and MMP-8 (r = 0.630; p = 0.050), between CD8(+) T cells and MMP-9 (r = 0.648; p = 0.043), and between CD56(+) NK cells and MMP-3 (r = 0.828; p = 0.003) compared to controls. CONCLUSIONS: The positive relationship of serum MMP-3, -8 and -9 with immune cells in children with Down syndrome may facilitate migration of CD8(+) T cells and CD56(+) NK cells into the periodontal tissue, which may contribute to the increased degradation of periodontal tissue in individuals with Down syndrome.

Altered relationship between MMP-8 and TIMP-2 in gingival crevicular fluid in adolescents with Down's syndrome.

BACKGROUND AND OBJECTIVE: Periodontitis is more frequently found in subjects with Down's syndrome. The aim was to investigate whether the relationship between MMPs and TIMPs) in the gingival crevicular fluid of subjects with Down's syndrome is altered compared with controls. MATERIAL AND METHODS: Twenty-one adolescents with Down's syndrome and gingivitis (DS-G), 12 subjects with Down's syndrome and periodontitis (DS-P), 26 controls with gingivitis (HC-G) and eight controls with periodontitis (HC-P) were clinically examined. All patients were between 11 and 20 years of age. Gingival crevicular fluid was collected from each subject and the concentrations of MMPs (2, 3, 8, 9 and 13) and TIMPs (1, 2 and 3) (expressed as pg/µL adjusted for volume of gingival crevicular fluid) were determined using multianalyte kits from R&D Systems. RESULTS: The concentrations of MMP-2, MMP-3, MMP-8, MMP-9 and TIMP-2 in gingival crevicular fluid were significantly higher (p < 0.005) in the DS-G group compared with the HC-G group. The correlation coefficient between MMP-8 and TIMP-2 differed significantly (p = 0.006) between the DS-G group and the HC-G group. On the contrary, the correlation coefficients between MMPs and TIMPs did not differ significantly between the DS-P group and the HC-P group. However, the DS-P group exhibited a significantly lower concentration of TIMP-2 in the gingival crevicular fluid compared with the HC-P group. CONCLUSION: Down's syndrome subjects with gingivitis exhibit higher concentrations of MMPs in gingival crevicular fluid with an altered relationship between MMP-8 and TIMP-2, which might impair the periodontal tissue turnover.

Detection of approximal caries in 5-year-old Swedish children.

The aim was to assess how accurately some commonly used risk factors/risk markers (predictors) for caries development could identify children with and without approximal caries as judged from bitewing radiography. Two hundred and sixty-seven consecutive 5-year-old children from two Swedish cities participated. Three experienced dentists examined the children. The predictors were the overall dmfs (decayed, missing and filled surfaces) value (canines and molars), the number of occlusal dmfs, the frequency of intake of between-meal sugary products, visible plaque on free smooth surfaces of second primary molars, toothbrushing habits and (before bitewing examination) an overall judgement by the examining dentist. The mean dmfs value without bitewing examination was 0.40 (SD = 1.22). Twelve percent of the children had at least one dentin lesion and 33% at least one enamel lesion that were detected from bitewing examination only. The gain from adding bitewing examination to clinical examination amounted to a mean of 1.2 approximal enamel and/or dentin lesions. The ability to correctly identify children with approximal caries from the predictors was limited; sensitivity ranged from 0.27 to 0.75 and specificity ranged from 0.41 to 0.93. The single best predictor was the dentist's overall judgement with an average precision of 73%; average sensitivity for the presence of enamel and dentin lesions was 0.48 and for the presence of dentin lesions 0.66. The rest of the predictors added little to the predictive power. It is concluded that 33% of the 5-year-olds, representing a low caries prevalence population, benefited from bitewing examination. The ability to identify these children from the predictors was, however, limited.

A logbook for continuous self-assessment during 1 year in paediatric dentistry.

AIM: The present study was designed to investigate whether a logbook helps undergraduate students to develop the ability to self-reflect and to increase their self-awareness. METHODS: A logbook was introduced to 54 dental students in their fourth year of education at the beginning of the paediatric dentistry course. The students filled in a questionnaire on learning styles at the start of the course and after 12 months. RESULTS: The results showed that at the end of the course significantly fewer students wished to be given detailed instructions to solve problems. Significantly more students felt able to expose both their weaknesses and strengths in clinical competence in the presence of their teachers. Students who reported a good knowledge of their own clinical skills found feedback from instructors more constructive compared with those who reported less good knowledge. CONCLUSION: For a large group of students, the logbook stimulated self-reflection, learning from personal clinical experience, and an increase in knowledge about their weaknesses and strengths in clinical competence.