The role of the consultant in restorative dentistry.

The role of a hospital consultant has changed extensively over the past decade as the National Health Service has progressed through a series of challenges including an ageing population and rising costs of clinical care. The traditional concept of a consultant has changed with different and increased expectations of the role as the pressures to deliver high quality patient care, education and advice continue to rise in a difficult financial climate. In addition, consultants in restorative dentistry are faced with the challenge of a poor general awareness of the scope of their speciality and their role. This paper provides an update on how the role of the consultant in restorative dentistry has evolved in the last decade and how it differs from that of other dental specialists and general dental practice.

Risk-based management of dental procedures in patients with inherited bleeding disorders: Development of a Dental Bleeding Risk Assessment and Treatment Tool (DeBRATT).

INTRODUCTION: Successful outcomes in dental management for patients with inherited bleeding disorders require close collaboration between haematology teams and dentists. AIM: To review outcomes of an interdisciplinary pathway for dental procedures by assessing adequacy and appropriateness of haemostatic management. METHODS: Two hundred dental procedures in 30 patients with inherited bleeding disorders were included. A Dental Bleeding Risk Assessment and Treatment Tool (DeBRATT) was developed to identify four categories of bleeding risk (no risk, low, moderate and high risk of bleeding) in relation to the severity of the bleeding disorder and the invasiveness of dental procedure. The adequacy and appropriateness of haemostatic therapy provided in relation to the bleeding risk was assessed with reference to the published literature. Treatment was classified as appropriate, over or under-treatment. Bleeding complication was the primary outcome. RESULTS: A high level of dental disease was noted, with 83% of patients having at least one decayed tooth and 46.7% having chronic gum disease. A total of 59.1% of the dental procedures in patients with mild bleeding disorders were over-treated (n = 65/110) and 8.9% in patients with severe disorders had an extended duration of treatment (n = 7/79). One bleeding complication was observed in a patient with Von Willebrand's disease and severe thrombocytopenia. All other procedures (99.5%) were uneventful. CONCLUSION: DeBRATT enables a risk-based approach for the management of dental procedures in patients with inherited bleeding disorders. The tool facilitates a comprehensive evaluation of bleeding risk with the potential to minimize unnecessary treatment and aid interdisciplinary communication among different clinical teams.

External cervical resorption associated with localized gingival overgrowth.

AIM: To describe the presentation and management of an unusual lesion of external cervical resorption. SUMMARY: The salient features of this unusual presentation of the external cervical resorption with localized gingival overgrowth, and the resorption located almost wholly on the labial aspect of a maxillary incisor crown are described. Extensive loss of enamel had occurred. The management and possible aetiology of the resorptive lesion are discussed. KEY LEARNING POINTS: Localized gingival overgrowth can be associated with external cervical resorption.The cervical resorption does not necessarily indicate pulp canal infection and the need for root-canal treatment.

Tooth wear treated with direct composite restorations at an increased vertical dimension: results at 30 months.

STATEMENT OF PROBLEM: Severe tooth wear localized to the anterior maxillary or mandibular teeth with loss of interocclusal space is difficult to manage. PURPOSE: This study evaluated the outcome of composite restorations placed at an increased vertical dimension of occlusion in such patients. METHODS AND MATERIAL: Sixteen patients were restored with 104 restorations in 2 groups. In group A, Durafill composite and Scotchbond Multipurpose dentine adhesive system were used to place direct anterior restorations (N = 52). In group B, Herculite XRV composite and Optibond dentine bonding agent was used (N = 52). The restorations were placed at an increased vertical dimension of occlusion creating a posterior disclusion of 1 to 4 mm. RESULTS: Clinical follow-up showed that the posterior occlusion remained satisfactorily restored after a mean duration of 4.6 months (range 1 to 11 months). Mean follow-up of 30 months has shown a combined success rate of 89.4% for both groups with 93 of the restorations remaining in service. Maintenance in group A was high with 33 failures, but low in group B with 6 failures. Patient satisfaction was reported as good. CONCLUSION: Direct composite restorations may be a treatment option for localized anterior tooth wear.

Immediate anterior tooth replacement using fibre-reinforced composite.

The loss of anterior teeth can be psychologically and socially damaging to the patient the trauma of which can be minimized by immediate replacement of the teeth, preferably using a fixed prosthesis. This paper describes the immediate replacement of a lateral incisor using a fibre-reinforced composite with the natural tooth as the pontic. The abutment teeth can be conserved with minimal or no preparation, thus keeping the technique reversible, and can be completed at the chairside thereby avoiding laboratory costs. It can be used as an interim measure or as a definitive prosthesis. The advantages of this technique over other methods are also discussed.

Post-extraction bleeding--an aid to diagnosis? Case report.

Haemophilia A, the most common of bleeding disorders is characterized by bruising and spontaneous bleeding into the joints but may remain undiagnosed if present in the mild form. A case is discussed where episodes of bruising and joint swelling as a child were misdiagnosed as rheumatic fever and the bleeding disorder was diagnosed following recurrent episodes of bleeding after extraction of an upper molar tooth.

Case report: tooth wear associated with an unusual habit.

Pathological tooth wear is an increasing problem affecting a significant proportion of the population. Although different wear mechanisms have been described, most reports in the literature concentrate on cases in which the predominant mechanisms were erosion and attrition. This article presents an unusual case of abrasive tooth wear caused by a sand eating habit which the patient had adopted as a child. Different causes of "abrasive" wear are discussed and the difficulties in management of this case are also presented.

Particulate bioglass as a grafting material in the treatment of periodontal intrabony defects.

The present clinical trial was designed to evaluate the effects of a bioactive glass, Perioglas, in the treatment of periodontal intrabony defects. 20 patients, 23-55 years of age (44 sites), with intrabony defects completed the 1-year study. Teeth with furcation involvement were excluded. After completion of initial therapy, defects were randomly assigned to either a test or control procedure. Following flap reflection, root planing and removal of chronic inflammatory tissue in both groups, the test defects were restored with the bioactive glass particulate material. Mucoperiosteal flaps were replaced, sutured and a periodontal dressing was used. All the patients received postoperative antibiotics and analgesics and were seen at 1 week for suture removal. Follow-up was then carried out weekly and at 3 months, 6 months, 9 months and 1 year post-surgery. Plaque score, bleeding score, probing pocket depth (PPD), probing attachment level (PAL) and gingival recession were recorded at baseline, 3 months and 1 year. Standardised radiographs for computer-assisted densitometric image analysis (CADIA) were taken at baseline, immediately post-operatively and at 1 year. The CADIA data showed a significant increase (F-ratio: 15.67, p < 0.001) in radiographic density and volume between the defects treated with the Perioglas when compared to those treated with surgical debridement only. PPD and PAL showed significant improvements in both experimental and control sites, with a greater trend to improvement in the experimental sites. It was concluded that this bioactive glass is effective as an adjunct to conventional surgery in the treatment of intrabony defects.

Treatment of localized anterior toothwear with composite restorations at an increased occlusal vertical dimension.

Patients may present with localized anterior toothwear, complaining of poor appearance or sensitivity, or both. Restoration of these teeth continues to cause problems, especially if interocclusal space has been lost. Conventional treatment to satisfy the patient's aesthetic and functional demands is time consuming and requires careful maintenance. This paper describes the use of chairside composite resin restorations in the treatment of localized anterior toothwear. Interoccusal space is provided by placing the restorations at an increased vertical dimension of occlusion. It enables the presenting complaint to be resolved while restoring structure, function and appearance.

Combined treatment approach to gingival overgrowth due to drug therapy.

A case of severe gingival overgrowth associated with combined drug therapy of cyclosporin A and nifedipine is reported. The frequently increased vascularity of the gingival tissues in such cases often causes problems with bleeding both during and after surgery. Acrylic suckdown splints have been used postoperatively to assist haemostasis; however, these can interfere with function and cause discomfort. This report describes a combined treatment approach using conventional gingivectomy and carbon dioxide laser for the removal of the hypertrophic soft tissue. The benefits of such combined treatment include reduced bleeding during surgery with consequent reduced operating time and rapid post-operative haemostasis, thus eliminating the need for a splint.

Finite element analysis of stress distribution at the tooth-denture base interface of acrylic resin teeth debonding from the denture base.

Acrylic resin teeth present a problem when they detach unexpectedly from the denture base resin. Detachment is caused by stress concentrations at the tooth/denture base resin interface. In this study, the finite element method was used to examine the stress distribution at this interface when a single static force that resembled incisal bite force was applied. The results indicated that irrespective of the type of acrylic resin teeth used, maximum tensile stresses were found at the palatal aspect of the interface. It is suggested that boxing the tooth in the acrylic resin will help redistribute stress concentrations favorably.

An immediate resin-bonded bridge using the natural tooth.

Missing anterior teeth are commonly replaced immediately with partial dentures, but this may cause embarrassing problems and a poor aesthetic appearance. This paper describes a technique for replacing anterior teeth using the natural tooth as a pontic with a resin-bonded cast metal framework. The main advantage of this technique is that a fixed restoration is provided on the same day as the tooth is removed, providing a major psychological benefit to the patient and maintaining the aesthetics. The short-term results are promising- and recent advances in adhesive dentistry mean that the long-term result should be equally as good.

Stress analysis techniques in complete dentures.

The fracture of acrylic resin dentures remains an unresolved problem. It is known that eventual fracture of an appliance occurs due to crack initiation and propagation from areas of high stress concentration. In order to understand and overcome the problem of fracture, it is important to identify the regions of stress concentration. A number of different methods are used in stress analysis. However, the finite element method, a numerical technique, appears to overcome most of the problems associated with the earlier experimental methods. This article reviews the different techniques and their application to examining stresses in dentures.

Denture fracture--a survey.

The fracture of dentures is an unresolved problem. Despite increasing costs incurred by the nation on the repair of these prostheses, very little has been documented on the type of fracture encountered. This survey was carried out to determine the prevalence of type of fracture by the distribution of questionnaires to three different laboratories. Results obtained showed that 33% of the repairs carried out were due to debonded/detached teeth. Twenty-nine per cent were repairs to midline fractures, more commonly seen in upper complete dentures. The remaining 38% were other types of fractures, the majority of which constituted repairs to upper partial dentures. The latter involved detachment of acrylic resin saddles from the metal in metal based dentures and the fractures of connectors in the all-acrylic resin partial dentures.

The treatment of palatal erosive wear by using oxidized gold veneers: a case report.

Eight maxillary anterior teeth with severe palatal erosion in an anorexic patient were restored with oxidized gold veneers and without tooth preparation. Because of the extensive exposure of dentin, a cement based on 4-methacryloxyethyl trimellitate anhydride was used as the luting agent.

The effect of impurities on the stress distribution at the tooth/denture base resin interface.

The most common cause of teeth detaching from the denture base is the presence of impurities along the tooth denture-base interface. However detachment after a period of wear of the denture probably occurs due to the presence of stress concentrations along the interface from which cracks may initiate. The presence of the impurity will inevitably lower the stress threshold for cracks to propagate thereby increasing the risk of tooth detachment. Although this is obvious, there is no evidence to show the effect of impurities on the stress distribution at this interface. This pilot study utilised the finite element method to examine stresses at the tooth-denture base interface in the presence of simulated impurities interspersed along different positions on the interface. Within the limitations of the two-dimensional model used, it was concluded that the presence of an impurity at the edge of the palatal aspect of the interface has a significant effect on the stress magnitude. However, the presence of impurities elsewhere along the interface had no significant effect on the stress magnitude. This would have important implications during the processing of dentures.

Multiple external root resorption. Case report.

A case of a patient with multiple external root resorption affecting principally the molars and premolars is described. This case is unusual in that although both right and left molar and premolar teeth are involved, the resorption is worse on the left side and affects only the distal roots of the molars.

The tooth-denture base bond: stress analysis using the finite element method.

Although acrylic resin teeth are the most popular artificial teeth used for denture construction, a high number fracture away at the tooth-denture base interface. Various causes have been documented for this failure; however, it is logical that eventual fracture occurs due to localised tensile stresses at this interface. Examination of these stresses using the finite element method showed that on load application to the upper incisors, the maximum tensile stresses were concentrated within the body of the tooth and not at the tooth-denture base interface. Stresses encountered at the interface were relatively low and introduction of a crack made no significant difference to their magnitude.

The periodontal abscess--a case report.

Determining the causative factors of dental abscesses continues to tax the diagnostic skills of clinicians. A case is discussed of an unusually presenting chronic periodontal abscess involving the bifurcation of the upper left first premolar.