A video-based decision aid improved knowledge and decreased decisional conflict for asymptomatic persistent endodontic lesions.

AIM: This prospective cohort study aimed to (i) evaluate patients' treatment decisions, decisional conflict and knowledge levels before and after use of a video-based decision aid (DA) on asymptomatic persistent endodontic lesions (APEL) and to (ii) elicit important decision factors for patients in the decision-making process. METHODOLOGY: A video DA modelled after the International Patient Decision Aids Standards (IPDAS) was designed. The video was pilot-tested, revised and used on 50 patients referred to the graduate endodontic clinic and presenting with an incidental finding of APEL detected on radiographs, with informed consent (DSRB 2020/00133). Recruitment was conducted from June 2020 to November 2021. Patients' treatment decisions and decision-making process were studied. Patients also completed a questionnaire on knowledge gain, decisional conflict and confidence levels. RESULTS: Forty-three patients (48 teeth) out of 50 patients chose long-term monitoring of APEL while 7 patients (7 teeth) decided on endodontic intervention. Median knowledge scores increased from 58.3 (IQR: 41.7, 75.0) to 87.5 (IQR: 75.0, 100.0) (p < .001); median decisional conflict scale (DCS) scores decreased from 25.0 (IQR: 12.5, 34.4) to 3.1 (IQR: 0, 23.8) (p < .001), and 44 (88%) patients were confident or very confident with their treatment decisions. Statistical analyses showed that asymptomatic condition of tooth was the sole decision factor with statistical significance while socioeconomic factors (age, gender, race, education and income levels) showed no significant trend. CONCLUSIONS: The majority of patients presenting with APEL in this study chose long-term monitoring over immediate intervention. Using the video-based DA in the decision-making process significantly improved patients' knowledge and decreased their decisional conflict levels.

Specimen Shape and Elution Time Affect the Mineralization and Differentiation Potential of Dental Pulp Stem Cells to Biodentine.

The liquid extract method is commonly used to evaluate the cytotoxicity and bioactivity of materials. Although ISO has recommended guidelines for test methods, variations in elution period, and shape of samples can influence the biological outcomes. The aim of this study was to investigate the influence of material form and elution period of Biodentine on dental pulp stem cells (DPSCs)' proliferation and mineralization. Biodentine (0.2 g) discs or powder were immersed in culture media (10 mL) for 1, 3 or 7 days (D1, D3 and D7). The eluents were filtered and used to treat DPSC. The calcium release profile and pH were determined. Cell proliferation was evaluated by MTS for 3 days, and mineralization and differentiation were assessed by alizarin red S staining (Ca2+/ng of DNA) and qRT-PCR (MEPE, DSPP, DMP-1, RUNX2, COL-I and OCN) for 14 days. Statistical analysis was performed with a one or two-way ANOVA and post hoc Tukey's test (pH, calcium release and proliferation) or Mann-Whitney test (α = 0.05). pH and calcium ion release of powdered eluents were significantly higher than disc eluents. Powdered eluent promoted extensive cell death, while the disc form was cytocompatible. All disc eluents significantly increased the gene expression and mineralization after 14 days compared to the untreated control. D7 induced less mineralization and differentiation compared to D1 and D3. Thus, the materials' form and elution time are critical aspects to be considered when evaluating the bioactivity of materials, since this binomial can affect positively and negatively the biological outcomes.

Influence of cone beam computed tomography on endodontic treatment planning: A systematic review.

OBJECTIVES: The aim of this systematic review was to evaluate how treatment plans changed when cone beam computed tomography (CBCT) imaging was used in endodontic treatment decision-making. DATA: Studies examining changes in clinicians' treatment plans with and without the use of CBCT were included. Risk of bias assessment was completed using a modification of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. SOURCES: A systematic search was performed in PubMed, Embase, Scopus, Cochrane databases from inception to 14 September 2021. STUDY SELECTION: The initial search identified 3379 titles and abstracts; 20 articles fulfilled inclusion and exclusion criteria for full text review. An additional three articles were identified through citation searching. Sixteen studies met inclusion and exclusion criteria for data extraction and analysis. Fifteen studies reported changes in treatment plan with CBCT imaging. Five studies reported changes in 45 - 66.7% of the cases but did not mention specific treatment options. Of the 11 remaining studies, 10 studies reported changes in 24.3 - 56% of cases and changes in treatment options, while one study reported no significant change in treatment plan after CBCT imaging was introduced. With CBCT imaging, clinicians were more likely to prescribe further intervention that included endodontic treatment and extractions. CONCLUSION: Although the current evidence was heterogeneous, it was clear that CBCT offered more information than periapical radiography. This influenced endodontic treatment decision-making and in more complex cases, led to further intervention including non-surgical and surgical endodontic treatment and extractions. CLINICAL SIGNIFICANCE: Additional information from CBCT imaging influenced endodontic treatment decision-making in the following situations: high difficulty cases, diagnosis of symptomatic teeth after failed root canal treatment, evaluation of periapical healing, pre-surgical treatment planning, and management of traumatised immature teeth and external cervical resorption.

Characteristics of Cracked Teeth with Reversible Pulpitis After Orthodontic Banding-A Prospective Cohort Study.

INTRODUCTION: Cracked teeth with reversible pulpitis can be managed with orthodontic bands in the interim before definitive restorations. The aim of this study was to determine short-term outcomes of these teeth following orthodontic band placement. The time taken for definitive pulp diagnoses after orthodontic band placement and associated prognostic factors was also analyzed. METHODS: One hundred twenty-five patients with a cracked tooth with reversible pulpitis each were recruited. Preoperative data including patient and tooth factors were collected. Cracked teeth were banded and reviewed until symptoms resolved before referral for coronal coverage. Kaplan-Meier and Cox analyses were performed to analyze pulp survival of these teeth. Prognostic factors were investigated using Pearson's chi-square and Student's t-test. RESULTS: One hundred twenty-two cracked teeth were analyzed. One hundred thirteen (92.6%) teeth had the pulpitis resolved within 2 months (median 40.0; interquartile range 28-61). The median time taken for progression to irreversible pulpitis or pulp necrosis for teeth that required root canal treatment was 3 months (median 90.0; interquartile range 68-110). No prognostic factors were associated with the resolution of pulpal symptoms. However, higher preoperative triggered pain scores (P < .05, hazards ratio 1.547) and absence of a distal marginal ridge crack (P < .05, hazards ratio 0.638) were correlated with a longer duration before definitive pulp diagnoses. CONCLUSION: Following orthodontic band placement, a normal pulp diagnosis was achieved in 92.6% of cracked teeth with preoperative reversible pulpitis. Definitive pulp diagnoses could be determined in approximately 2 months. Teeth with higher preoperative triggered pain scores may require a longer review period.

Psycho-social perspectives of nonsurgical versus surgical endodontic interventions in persistent endodontic disease.

INTRODUCTION: Patients' experiences related to dental treatment could influence care-seeking behaviour and engender personal bias. Although endodontic retreatment and apical surgery are procedures often performed to manage previously treated teeth with persistent disease, there is lack of information regarding psycho-social perspectives of patients who undergo these treatments. Our aim was to compare experiences of patients who received these two treatment modalities using a qualitative approach. METHODS: A purposive sample of patients was taken from our previous study utilizing the Oral Health Impact Profile to compare oral health-related quality of life of 150 patients who received retreatment and apical surgery. Patients who reported impact and no impact were invited to participate in focus group discussions (FGDs). Eighteen patients from the retreatment group and 15 patients from the surgical group participated in six FGDs. Thematic analysis was conducted to identify key themes. RESULTS: Four themes emerged: (1) psycho-social disability associated with dental procedures, (2) physical disability associated with dental problems, (3) reliance on dentist's advice for treatment and (4) self-management to preserve treated teeth. Patients undergoing endodontic retreatment reported significant time loss from work and were less informed of alternative treatment options. However, they were pleased with the aesthetics of their teeth, especially if new crowns were made. Patients undergoing surgery experienced anxiety related to loss of control during surgery and apprehension on visualizing the wound post-surgery. They reported more impact on their diet, social interaction and sleep quality and some felt self-conscious due to post-treatment gingival recession. Patients in both groups placed great trust in professional advice and expressed a clear desire to maintain their natural dentition. There was low awareness regarding long-term care and future sequelae of their treated tooth. CONCLUSIONS: Patients reported different psycho-social and physical impacts following endodontic retreatment and apical surgery. Patients undergoing endodontic retreatment were more satisfied with aesthetic outcomes but experienced greater impact related to complexities and length of time taken for treatment. Patients undergoing surgery were better informed of treatment options but experienced greater physical and psycho-social disability during the recovery phase. Clinicians could consider incorporating findings from this study into the patient-dentist discussion.

Management of cracked teeth: Perspectives of general dental practitioners and specialists.

OBJECTIVES: The main aim of this study was to compare how general dental practitioners (GDPs), endodontists and prosthodontists diagnose, prognosticate, and treat cracked teeth. The secondary aim was to highlight factors influencing GDPs' referral practices of cracked teeth to specialists. MATERIALS AND METHODS: Questionnaires were used to collect information from GDPs, prosthodontists, and endodontists, on their use of diagnostic methods to identify cracked teeth, prognostication, and their management and referral practices for cracked teeth. Descriptive statistics were used to summarize the quantitative data. Pearson's Chi-Square test or Fisher's Exact test was applied to categorical variables while Kruskal-Wallis or Spearman's correlation coefficient was applied to continuous variables (p <0.05). Content analysis was performed for qualitative data. RESULTS: 207 dentists responded, resulting in a response rate of 83.5%. Endodontists used more diagnostic tools as compared to prosthodontists and GDPs. For pulpally involved cracked teeth, endodontists were more likely to recommend root canal treatment (RCT) and cuspal coverage compared to extraction, followed by prosthodontists then GDPs. Main reasons for referral of cracked teeth to specialists include uncertainty in diagnosis, difficulty in crack visualization after endodontic access, and cracked teeth indicated for RCT. CONCLUSION: GDPs, prosthodontists, and endodontists differ in terms of their diagnosis, prognostication, and treatment of cracked teeth. GDPs refer cracked teeth to specialists due to challenges faced in diagnosis and treatment. Future research and education are required to provide evidence-based guidelines in the management of cracked teeth so that patients with cracked teeth can receive standardized care.

Postobturation Pain Associated with Tricalcium Silicate and Resin-based Sealer Techniques: A Randomized Clinical Trial.

INTRODUCTION: The incidence of immediate postobturation pain associated with 2 sealer techniques was compared and potential prognostic factors identified. METHODS: Patients referred for endodontic treatment were recruited with informed consent. Root canals were debrided and teeth rendered asymptomatic before random allocation to receive TotalFill BC (FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) or AH Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland). Patients blinded to the sealer reported their postobturation pain experience 1, 3, and 7 days after treatment. Blinded and calibrated assessors independently reviewed treatment quality, sealer extrusion, and radiographic data under standardized conditions. RESULTS: One hundred sixty eligible patients (163 teeth, 95.3%) returned their pain diary. No postobturation pain difference was found between the 2 sealers (P > .05), although the AH Plus sealer technique was significantly associated with extrusion beyond the apex (P < .05; odds ratio [OR] = 3.02; 95% confidence interval [CI], 1.39-6.57). Thirty-three (20.6%) patients reported pain on day 1 (median 1 = very mild pain), 16 (10.0%) on day 3 (median 1 = very mild pain), and 9 (5.6%) on day 7 (median 2 = mild pain). The prognostic factors were as follows: (1) moderate/severe preoperative pain (OR = 4.41; 95% CI, 1.42-13.76 on day 3 and OR = 5.16; 95% CI, 1.17-22.78 on day 7), (2) provoked preoperative pain (OR = 4.24; 95% CI, 1.40-12.78 on day 3 and OR = 5.35; 95% CI, 1.27-22.51 on day 7), (3) pulpless tooth (OR = 0.11; 95% CI, 0.02-0.57 on day 3), and (4) sonic activation during treatment (OR = 3.02; 95% CI, 1.39-6.57 on day 1 and OR = 3.01; 95% CI, 1.05-8.59 on day 3). CONCLUSIONS: There was no significant difference in pain experience between teeth filled using AH Plus or TotalFill BC Sealer 1, 3, and 7 days after obturation. Patient- and treatment-related factors could influence postobturation pain.

Factors Influencing Quality of Life after Surgical and Nonsurgical Interventions of Persistent Endodontic Disease.

INTRODUCTION: Nonsurgical endodontic retreatment and apical surgery are predictable procedures for the management of endodontically treated teeth with persistent disease. However, there is no information available that compares these treatment modalities based on patients' oral health-related quality of life (OHRQOL). The aims of this study were to compare the OHRQOL of patients who received nonsurgical endodontic retreatment versus those who received apical surgery and to identify correlations between OHRQOL, clinician-assessed healing outcome, and other factors. METHODS: Patients who received treatment at 2 dental hospitals with a recall period of 6-24 months were invited to participate. They underwent follow-up examination and were surveyed with the Oral Health Impact Profile (OHIP-14). Healing outcomes were determined by clinical and radiographic evaluation. Potential influencing factors for OHIP-14 scores were investigated. RESULTS: One hundred fifty patients (75 patients from each group) participated in the study. There were no differences in OHIP-14 scores between both groups at the follow-up. The overall adverse impact on OHRQOL was low, with patients experiencing greater impact in the domains of "physical pain" and "psychological discomfort." Women and patients who had preoperative pain reported a greater impact. There was an overall high healed and healing rate for both groups. No correlation was found between OHIP-14 scores and healing outcome. CONCLUSIONS: Patients who received nonsurgical endodontic retreatment and apical surgery reported comparable OHRQOL, with women and patients with preoperative pain reporting greater impact. Both treatments are viable options for the management of persistent endodontic disease based on clinician- and patient-reported outcome assessments.

Long-term Pulpal and Restorative Outcomes of Pulpotomy in Mature Permanent Teeth.

INTRODUCTION: Pulpotomy in mature permanent cariously exposed teeth preserves the remaining pulp tissues, but long-term outcomes of the pulp and the restoration are unknown. This prospective study examined the immediate and long-term status of the pulp and the restored tooth and identified potential predictors of early and late failures in teeth that were asymptomatic or experiencing only mild symptoms at the time of treatment. METHODS: Pulpotomy was performed using the aseptic technique and a tricalcium silicate cement under local anesthesia. Teeth were assessed for up to 5 years for pulpal and apical signs and symptoms, restorative marginal integrity, and periodontal health. RESULTS: Fifty-two patients (61 teeth) with a median age of 40 years (range, 21-75 years) were included in this study; 17 (32.7%) men and 35 (67.3%) women were treated and reviewed. Overall pulp survival was 90.2% (95% confidence interval, 79.8%-96.3%); 6 teeth developed irreversible pulpitis or pulp necrosis when the restoration was intact. Preoperative pain was a potential predictor (P < .05) for early failure. Eleven late failures occurred between 2 and 4 years: 1 tooth with intact coronal restoration had pulp necrosis and asymptomatic apical periodontitis, 4 had recurrent caries resulting in asymptomatic apical periodontitis, 4 remained vital and only needed new restorations, 1 was unrestorable, and 1 was extracted for periodontal reasons. The type of definitive restoration was a potential predictor for late failure (P < .05). CONCLUSIONS: Carious pulp exposures in asymptomatic mature permanent teeth can be predictably managed by pulpotomy using a tricalcium silicate cement. Short-term failures were few and managed by pulpectomy. Appropriate coronal restoration is critical to long-term success.

Understanding patients' and dentists' perspectives in dental trauma management: A mixed-methods study.

BACKGROUND/AIM: Patients suffering dental trauma are unprepared for the disability challenge and necessary rehabilitation, while a traumatic event places an expanded demand on the dentist who is focused on treating disease. The aim of this study was to examine the impact of traumatic dental injuries (TDI) on patients and to compare patients' and dentists' perceptions of the event. MATERIAL AND METHODS: TDI patients (aged ≥ 21 years) attending a tertiary dental hospital from 2011 to 2013, and their dentists were recruited with informed consent. An exploratory sequential mixed-methods design was adopted. The Oral Health Impact Profile (OHIP-14) quantitatively identified patients with "very often," "fairly often" or "occasionally" in at least one of the OHIP-14 questions (Phase 1) to participate in the qualitative phase of the study through focus group discussions (FGD) (Phase 2). FGD for dentists was conducted separately. RESULTS: Quantitative analysis showed 28%-55% of TDI patients had "occasional" to "very often" discomfort during eating, increased self-consciousness and embarrassment. Qualitative analysis showed patients were concerned with aesthetic disability, treatment cost and potential tooth loss but overcame their negative outlook and accepted prescribed protective measures. Dentists appreciated patients' concerns about aesthetics and functional disruptions but were less attuned to patients' sense of guilt and fear of judgement. CONCLUSIONS: TDI exert functional, psychological and social impacts on patients. Patients' and dentists' perspectives were useful for understanding the need for continuity of care, and the findings could contribute to effective TDI management.

Cysteamine Enhances Biofilm Eradication Efficacy of Calcium Hydroxide.

INTRODUCTION: Calcium hydroxide (Ca[OH]2) is a widely used interappointment dressing, but its antibacterial property is compromised by dentin. Hence, the addition of chlorhexidine (CHX) with Ca(OH)2 has been proposed. However, the antimicrobial efficacy of this mixture compared with Ca(OH)2 alone is currently still debatable. Cysteamine is a mucolytic agent used to reduce the viscosity of mucus through the disruption of proteins, which are also important components of the extracellular matrix of biofilms. The aims of this study were to determine the efficacy of cysteamine alone and in combination with Ca(OH)2 to eradicate Enterococcus faecalis biofilm compared with CHX with Ca(OH)2, and to determine if this effect is affected by dentin. METHODS: The biofilm eradication efficacies of Ca(OH)2 alone and with cysteamine were determined using 7-day E. faecalis biofilm cultured on dentin discs and compared with Ca(OH)2 with 2% CHX. The effects of dentin on the efficacies of Ca(OH)2 alone and with either cysteamine or CHX were examined. RESULTS: Cysteamine alone completely abolished E. faecalis biofilm at 200 mg/mL. The combination of Ca(OH)2 with either cysteamine at 10 mg/mL or 2% CHX completely obliterated E. faecalis biofilm. Cysteamine with Ca(OH)2 completely eradicated E. faecalis biofilm despite preincubation with dentin, whereas CHX with Ca(OH)2 was less effective. CONCLUSIONS: Cysteamine effectively eliminated E. faecalis biofilm and showed synergistic effects in combination with Ca(OH)2, which were unaffected by dentin. Hence, our findings support the use of cysteamine as a potential adjunct to Ca(OH)2 as an interappointment dressing.

Matrix Metalloproteinase Inhibitor as an Antimicrobial Agent to Eradicate Enterococcus faecalis Biofilm.

INTRODUCTION: Successful endodontic treatment outcomes require new strategies for the complete eradication of microbial biofilms in the root canal system. Matrix metalloproteinases (MMPs) are essential enzymes in microbial cell growth and homeostasis, and they require transition metal ion cofactors to function. Targeting MMP activity also preserves dentin collagen integrity. In this study, 1,10-phenanthroline-5,6-dione (Phendione), a metal chelator, was tested as a potentially novel antimicrobial agent against Enterococcus faecalis and inhibitor of human MMP in the root canal. METHODS: Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of Phendione on E. faecalis were determined. The antimicrobial properties of Phendione in the presence of dentin powder and various transition metal ions were examined. The ability of Phendione to inhibit human MMP-2 was subsequently tested. The efficacy of Phendione against E. faecalis biofilm was determined by exposure of 7-day-old E. faecalis biofilms to Phendione. RESULTS: The MIC and MBC of Phendione were 2.0 µg/mL and 16 µg/mL, respectively, whereas 64 µg/mL was required to kill E. faecalis biofilm. Phendione completely eradicated E. faecalis despite dentin preincubation. The presence of Zn(2+), and to a lesser extent Fe(2+), abrogated the antimicrobial effect of Phendione. In addition, Phendione at MIC and MBC significantly inhibited human MMP-2 activity. CONCLUSIONS: Phendione effectively eradicated E. faecalis biofilms and significantly inhibited human MMP-2 through its ability to chelate metal ions. The antibacterial property of Phendione was preserved in the presence of dentin. Phendione can potentially be applied in endodontic treatment as both an antimicrobial agent and MMP inhibitor.

Rapid method for the detection of root canal bacteria in endodontic therapy.

INTRODUCTION: Complete eradication of microorganisms is essential for successful root canal therapy. However, current methods to evaluate persistent bacteria after therapy are not widely practiced. Adenosine triphosphate (ATP) is an indicator of viable cells. The bioluminescence-based ATP assay is easy to perform, and results can be obtained in a clinically relevant time frame of 5 minutes. The aims of this study were to evaluate the sensitivity of the ATP detection method and the specificity of this assay for viable cells and to compare the ATP and culture methods from root canal samples of patients undergoing endodontic treatment. METHODS: The sensitivity of the ATP assay was determined using bacterial species commonly isolated from root canals. Bacteria were treated with sodium hypochlorite; after which, culture plating and the ATP assay were performed. Forty-three root canal samples before (S1) and after (S2) instrumentation and 36 samples after the removal of calcium hydroxide dressing (S3) were collected from patients undergoing root canal treatment and subjected to ATP assay and anaerobic culture. RESULTS: The sensitivity of the ATP assay was determined to be between 10 and 100 bacterial cells. This method of detection also correlated well with the presence of viable bacteria. The ATP readings obtained allowed clear segregation of anaerobic culture-positive and -negative samples obtained from infected root canals of patients. CONCLUSIONS: The ATP detection method can be used as a rapid tool to determine the presence of viable bacteria during root canal therapy. This method may be potentially useful as an adjunct to root canal treatment.

Lesion progression in post-treatment persistent endodontic lesions.

INTRODUCTION: Radiographic lesions related to root-filled teeth may persist for long periods after treatment and are considered to indicate failure of initial treatment. Persistent lesions are found in a proportion of cases, but information on lesion progression is lacking. This study examined the incidence of lesion improvement, remaining unchanged, and deterioration among persistent lesions in a group of patients recruited from a university-based clinic and identified potential predictors for lesion progression. METHODS: Patients of a university clinic with persistent endodontic lesions at least 4 years since treatment and with original treatment radiographs available were recruited with informed consent. Data were obtained by interview and from dental records and clinical and radiographic examinations. Univariate and multivariate statistical analyses were carried out by using SPSS (version 19). RESULTS: One hundred fifty-one persistent lesions were identified in 114 patients. A majority of the lesions (107, 70.9%) received treatment between 4 and 5 years prior. Eighty-six lesions (57.0%) improved, 18 (11.9%) remained unchanged, and 47 (31.1%) deteriorated since treatment. Potential predictors for lesions that did not improve included recall lesion size, pain on biting at recall examination, history of a postobturation flare-up, and a non-ideal root-filling length (P < .05). Lesions that had persisted for a longer period appeared less likely to be improving (relative risk, 1.038; 95% confidence interval, 1.000-1.077). CONCLUSIONS: A specific time interval alone should not be used to conclude that a lesion will not resolve without intervention. This study identified several clinical factors that are associated with deteriorating persistent lesions, which should aid in identifying lesions that require further intervention.

Incidence and impact of painful exacerbations in a cohort with post-treatment persistent endodontic lesions.

INTRODUCTION: Painful exacerbations of persistent periapical lesions have unknown incidence and impact on quality of life. This study examined the incidence and impact of painful exacerbations and evaluated potential predictive factors of pain associated with root-filled teeth with persistent lesions after root canal treatment. METHODS: Patients from a university hospital clinic were screened to identify root-filled teeth with periapical lesions at time of treatment and not resolved at least 4 years later. A clinical and radiographic examination and questionnaire survey were conducted. Patient and treatment characteristics and details of pain experience were studied. Statistical analysis was carried out by using SPSS (version 18). RESULTS: One hundred twenty-seven patients with 185 persistent lesions were recruited. Median age of patients at recruitment was 56 years (range, 21-82 years). Median time since treatment was 5 years (range, 4-38 years). Overall incidence of flare-up (requiring an unscheduled dental visit) was only 5.8% 20 years after treatment. Less severe pain was more frequent, with a combined incidence of 45% pain at 20 years after treatment. Female patients (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.2-6.0; P < .05), treatment involving a mandibular molar or maxillary premolar (OR, 3.7; 95% CI, 1.6-8.6; P < .05), and preoperative pain (OR, 2.9; 95% CI, 1.3-6.7; P < .05) were significantly associated with pain after treatment. The most commonly affected activities during painful exacerbations were eating and tooth brushing, with minimal impact on daily living. CONCLUSIONS: The risk of flare-up among persistent lesions was very low. A lower degree of pain was more common, but generally with minimal impact on daily activities.