Decisions on repositioning of intruded permanent incisors; a review and case presentation.

BACKGROUND: Traumatic intrusion is a luxation type of injury where the tooth is displaced along the axis of the tooth, into the alveolus. This injury is regarded as serious because of the tissue damage that it causes. The traumatic movement is associated with severe damage to the periodontal ligament, pulpal tissue, root and alveolar socket. Despite its severity, the rare occurrence of this injury in permanent teeth has resulted in limited studies of immature and mature permanent incisors. The purpose of this paper is to review this luxation injury of permanent immature incisors, and to describe its diagnosis, treatment and management. In particular, we describe the repositioning strategies used in cases of intrusion injury. These include (i) monitoring spontaneous re-eruption, (ii) active orthodontic repositioning and (iii) surgical repositioning. Firstly, monitoring spontaneous re-eruption is observing and waiting for the intruded tooth to return to its original position. This process is not a normal developmental eruption and the outcome is not always predictable, nor is the time needed for this to happen. Secondly, active orthodontic repositioning is used to describe the process of rapidly moving the intruded tooth to its original position with the aid of an orthodontic appliance. Active orthodontic repositioning is often misunderstood as normal orthodontic movement. Orthodontic movement allows for periodontal ligament remodelling, using light intermittent forces. In contrast the active orthodontic repositioning used to move intruded incisors is rapid, and the primary aim is to achieve correct tooth position as rapidly as possible. Thirdly, surgical repositioning uses surgical intervention to bring the tooth back to its original position. A case of an intruded immature permanent incisor is presented, with a particular emphasis on these critical decisions on repositioning and showing the use of the three modalities of treatment in sequence, in order to achieve an outcome.

A study of primary teeth restored by intracoronal restorations in children participating in an undergraduate teaching programme at Cork University Dental School and Hospital, Ireland.

AIM: To study the outcomes for restored primary molar teeth; to examine outcomes in relation to tooth type involved, intracoronal restoration complexity and to the material used. DESIGN: Retrospective study of primary molar teeth restored by intracoronal restorations. A series of restored primary molar teeth for children aged 6-12 years was studied. The principal outcome measure was failure of initial restoration (re-restoration or extraction). Three hundred patient records were studied to include three equal groups of primary molar teeth restored with amalgam, composite or glass ionomer, respectively. Restorative materials, the restoration type, simple (single surface) or complex (multi-surface) restoration, and tooth notation were recorded. Subsequent interventions were examined. Data were coded and entered into a Microsoft Excel database and analysis undertaken using SPSS v.18. Statistical differences were tested using the Chi square test of statistical significance. RESULTS: Of the 300 teeth studied, 61 restoration failures were recorded with 11 of those extracted. No significant differences were found between outcomes for upper first, upper second, lower first or lower second primary molars. Outcomes for simple primary teeth restored by intracoronal restorations were significantly better than those for complex intracoronal restorations (P = 0.042). Teeth originally restored with amalgam accounted for 19.7% of the 61 failures, composite for 29.5%, while teeth restored with glass ionomer represented 50.8% of all restoration failures. The differences were significant (P = 0.012). CONCLUSIONS: The majority (79.7%) of the 300 restored primary teeth studied were successful, and 3.7% teeth were extracted. Restorations involving more than one surface had almost twice the failure rate of single surface restorations. The difference was significant. Significant differences in failure rates for the three dental materials studied were recorded. Amalgam had the lowest failure rate while the failure rate with glass ionomer was the highest.

A review of the reasons and sources of referral to a hospital paediatric dental service in Ireland.

AIM: To examine the reasons for referral to the Paediatric Dental Department, Cork University Dental School and Hospital, Ireland and to study the profile of these reasons in terms of the various sources of referral. STUDY DESIGN: Clinical review. METHODS: Consecutive clinical records for children attending the service were reviewed with regard to a child's age at initial attendance, the reason for referral and the source of referral. Reasons for referral were recorded based on a defined list of acceptance criteria and were categorised by their different sources of referral. RESULTS: Records were available for 612 children with a mean age at time of initial consultation was 9.13 (SD+/- 3.94) years. Reason for referral; children who had difficulty co-operating for dental treatment made up the largest group (36.1%). Children who only required treatment planning comprised 25.0% of the total. Source of referral: 56.0% of consultations were from the salaried public dental service and 31.2% from private dental practitioners. Forty seven patients (7.7%) were from emergency department, while 31 (5.1%) were from medical practitioners. From the public dental service, 51.0% of referrals were for children who had difficulty co-operating for dental treatment and 22.7% were for treatment planning only. Referrals from private dental practitioners were most commonly for treatment planning only (38.2%). The proportion of referrals from the public dental service for children who had difficulty cooperating for dental treatment was twice as high as from private dentists. The proportion of referrals for trauma and for extensive dental disease from private dental practitioners was twice as high as from the public dental service. Almost all attendances from an emergency hospital department were for dental trauma. The majority of attendances from medical doctors were for medically at risk patients. CONCLUSIONS: Children with difficulty cooperating for dental treatment made up the largest single group of children attending the service. The majority of children attending were referred from the salaried public dental service.

Clinical audit of children with permanent tooth injuries treated at a dental hospital in Ireland.

AIM: To audit key demographic and clinical factors relating to treatment of trauma to the permanent dentition at the Paediatric Dental Department, Cork University Dental School and Hospital, Ireland and to compare clinical management with guideline recommendations. STUDY DESIGN: Clinical audit. METHODS: Consecutive clinical records for children attending for treatment of dental trauma were audited with regard to age, gender and distance travelled. The number of teeth per patient, the cause, type and prevalence of injury were examined. Splinting of mobilisation injuries and the prevalence of pulp extirpation were compared with published guidelines. RESULTS: Records were available for 94 children (65 male, 29 female) with a mean age at time of injury of 10.1 (SD±2.64) years. There were 82% of children living within 50 km of the Hospital. A total of 168 teeth were involved. Dental injuries comprised 39 uncomplicated crown fractures, 18 complicated crown fractures, 37 subluxations, 9 root fractures, 10 extrusions, 14 lateral luxations, 7 intrusions, 30 avulsions and 4 were unclassified. Sport injuries accounted for 23.2% of injuries to teeth, falls for 22.6%, bicycles were involved in 15.5%, other domestic accidents 6.5%, assault 4.2%, vehicles 3.0%, swimming 0.6%. and the remaining 24.4% were unclassified. In some instances of avulsion, lateral luxation, subluxation and extrusion injuries, a tendency to splint for durations longer than that recommended in guidelines was observed. Prevalence of pulpal extirpation for replanted teeth was in keeping with recommendations. CONCLUSION: General adherence to guidelines in respect of splinting and prevalence of pulp extirpation was demonstrated. Utilising a standardised recording system would facilitate the clinical audit process.

A study of the management of 55 traumatically intruded permanent incisor teeth in children.

AIMS: These were to examine the main presenting, treatment and outcome factors for intruded permanent incisors in children, the effect of apical development and degree of intrusion on decisions on repositioning, the effect of apical development status on the maintenance of pulp vitality and the time of pulp extirpation and to compare the decisions made to the advice given in existing clinical guidelines. METHODS: A sample of 55 intruded incisor teeth in 40 children aged between 6 and 14 years of age was reviewed in respect of management of their intrusive dental injuries. Of these teeth 17 were intruded in females and 38 in males. Mean (+/-SD) age was 9.3 (+/-1.99) and mean follow-up time was 2.3 years (+/-1.60). Included in the sample were 42 maxillary central incisors and 13 maxillary lateral incisors. RESULTS: Immature apicies were noted in 34 whilst 21 teeth had mature apices. Clinical and radiographic assessment categorised 4 teeth as mildly intruded with displacement of less than 3 mms; 10 teeth, intruded by 3-6 mm, were considered as moderately intruded whilst a further 11 teeth with intrusion of more than 6 mm were considered to have experienced a severe intrusive injury. There were 19 teeth (35%) that were allowed to re-erupt spontaneously, 22 (40%) were repositioned by orthodontic means and 14 teeth (25%) received surgical repositioning. CONCLUSION: There was a statistically significant difference between the repositioning decisions with a more conservative approach for teeth with immature apices (P = 0.0009). Apical completion was a significant predictor of earlier pulp extirpation (p=0.01).

Levels of oral disease in a sample of children with disability; a study carried out prior to comprehensive dental treatment under general anaesthesia.

AIM: To audit the levels of oral disease in those children whose disability required general anaesthesia for comprehensive dental treatment. METHODS: An audit was conducted of oral disease levels in a sample of 51 children attending for treatment. RESULTS: The proportion of untreated decayed teeth was 72%, previously extracted 25% and restored 3%. Very high levels of debris and gingival bleeding indices were found. There were very low proportions of previous restorations and past treatment had comprised mainly extractions. CONCLUSIONS: There was a low restorative care index in both the primary and permanent dentitions indicating that high needs continue to exist in terms of comprehensive dental care for these Irish children.

Parry-Romberg syndrome: a report of the dental findings in a child followed up for 9 years.

INTRODUCTION: The incidence of Parry-Romberg syndrome (PRS) is very rare. CASE REPORT: A case report is presented highlighting the main dental aspects that include delayed eruption, root resorption, dilacerations, and a reduction in the height and width of the ramus and body of the mandible on the affected side.

An exploratory study on cultural variations in oral health attitudes, behaviour and values of freshman (first-year) dental students.

OBJECTIVE: To identify similarities and differences in oral health attitudes, behaviour and values among freshman dental students. DESIGN: Cross-cultural survey of dental students. SETTING: 18 cultural areas. PARTICIPANTS AND METHODS: 904 first-year dental students completed the Hiroshima University-Dental Behavioural Inventory (HU-DBI) translated into their own languages. Individual areas were clustered by similarity in responses to the questions. RESULTS: The first group displayed an 'occidental-culture orientation' with the exception of Brazil (Cluster 1 comprised: Australia, United Kingdom, Ireland, Belgium and Brazil, Cluster 2: Germany, Italy, Finland and France). The second group displayed an 'oriental-cultural orientation' with the exception of Greece and Israel (Cluster 3 comprised: China and Indonesia, and Cluster 4: Japan, Korea, Israel, Hong Kong, Malaysia, Thailand and Greece). Australia and United Kingdom were the countries that were most alike. Ireland was the 'neighbour' to these countries. Greece and Malaysia had similar patterns of oral health behaviour although geographic conditions are very different. Although it was considered that in Hong Kong, occidental nations have affected the development of education, it remained in the oriental-culture group. Comparison with the data from the occidentals indicates that a higher percentage of the orientals put off going to the dentist until they have toothache (p < 0.001). Only a small proportion of the occidentals (8%) reported a perception of inevitability in having false teeth, whereas 33% of the orientals held this fatalistic belief (p = 0.001). CONCLUSIONS: Grouping the countries into key cultural orientations and international clusters yielded plausible results, using the HU-DBI.

Temporary arrest of root development in a premolar of a child with hypodontia and extensive caries.

The arrested development of a permanent tooth as a sequela to a periradicular infection in a primary predecessor is a rare occurrence. A case is presented where temporary arrest of root development occurred in a premolar of a child with hypodontia and extensive caries. The aetiology, management and outcome are discussed.

Drug metabolism and ageing.

Important changes in drug metabolism occur with ageing. Age-associated reductions in function of some but not all cytochrome P450 enzymes (CYPs) have been described. Induction and inhibition of CYPs needs to be revisited in light of recent advances. The function and pharmacology of transporters have not yet been examined for an age-related effect. Finally, the concept of frailty is being underpinned by studies documenting a decline in drug metabolism and changes in disposition in frail older people compared with either healthy elderly or the young.

Factors affecting outcomes of traumatically extruded permanent teeth in children.

PURPOSE: The objectives of the present study were to determine the prevalence of residual extrusion, pulpal necrosis, and resorption for extruded permanent teeth and to establish the effect of presentation and treatment factors. METHODS: Seventy-two traumatically extruded permanent incisors were studied at the Departments of Paediatric Dentistry in Belfast, Newcastle upon Tyne, and Glasgow. The mean age of the patients was 10.1 years (range=6 to 18 years). Clinical and radiographic outcomes were analyzed and related to presenting and treatment factors. RESULTS: The initial degree of extrusion was moderate for 46 teeth (64%), and the median delay prior to repositioning was 3 hours (range=1 to 168 hours). Pulp necrosis occurred in 31 teeth (43%), residual extrusion was present in 16 teeth (23%), and inflammatory resorption occurred in 11 teeth (15%). Residual extrusion was significantly associated with a delay in repositioning the tooth, pulpal necrosis was significantly more common in teeth with closed apices and in severely extruded teeth, and inflammatory resorption was more common after pulpal necrosis. CONCLUSIONS: Residual extrusion could be minimized by earlier presentation and repositioning. The risk of pulpal necrosis is greatest for severely extruded teeth and for those with closed apices.

Clinical pharmacology of old age syndromes.

Several syndromes occur in old age. They are often associated with increased mortality and in all there is a paucity of basic and clinical research. The recent developments in the clinical pharmacology of three common syndromes of old age (delirium, urinary incontinence, and falls) are discussed along with directions for future research.

Outcomes for root-fractured permanent incisors: a retrospective study.

PURPOSE: The objective of this study was to assess the outcomes for treated root-fractured permanent incisors with respect to pulp vitality, root tissue union, and tooth survival and to examine the effects of clinical and radiographic parameters and rigid splinting on the outcome. METHODS: Eighty-four teeth were identified and data extracted from case notes prior to transfer to an SPSS data base for analysis. The odds ratios for each factor were calculated and the significance of differences was determined. Tooth loss and relevant risk variables were examined using Cox's regression model and Kaplan-Meyer survival curves. RESULTS: Fourteen (17%) had fractures in the apical third, 47 (56%) in the middle third, and 23 (27%) in the coronal (gingival) third. Twenty-four (29%) also had crown fractures involving enamel and dentine. Crown fractures were identified as significant risk factors for pulp vitality. Loss of pulp vitality, horizontal displacement, and extrusive displacement of the coronal fragment were significant risk factors for hard root tissue union. Survival was poorest with gingival third fractures with 14 (61%) of these teeth being lost. Splinting rigidly had no significant effect on pulp vitality and type of root tissue healing. CONCLUSIONS: Loss of pulp vitality was significantly associated with enamel-dentine crown fracture. Hard root tissue union was significantly affected by pulp necrosis and luxation of the coronal fragment. Survival was poorest for root fractures within the gingival third of the root. Splinting with rigid fixation had no significant effect on pulp vitality and type of root tissue union.

Factors affecting the time of onset of resorption in avulsed and replanted incisor teeth in children.

Resorption is the main reason for loss of replanted teeth. The outcome examined in this study is the timing of the onset of resorption. The effect of dichotomised dry and wet time intervals as well as the presence of additional crown damage and of contamination were determined. Of 84 replanted teeth, 67.5% developed resorptions. Twenty-eight had detectable additional crown damage with a more rapid onset being seen in these cases (P=0.009). The critical limit for dry time was 15 min (P=0.038) and significant differences persisted for greater limits also. Serial analysis of the association between the time of onset of root resorption and dichotomised wet time variables failed to yield any significant associations. There was visible contamination detected in 32 teeth and these exhibited a more rapid onset of resorption than the other cases (P=0.030). Teeth with inflammatory root resorption (12.8%) had a more rapid onset of resorption than those that developed replacement resorption (54.7%) (P<0.001). It is concluded that the risk of early resorption is increased in teeth that have additional damage or have contamination, or are kept in dry conditions for longer than 15 min.

Effectiveness of the school dental screening programme in stimulating dental attendance for children in need of treatment in Northern Ireland.

UNLABELLED: The school dental screening programme has been in existence from the beginning of the 20th century yet its value in encouraging attendance among children with a dental health need is not fully established. OBJECTIVE: To evaluate the effectiveness of school dental screening in promoting dental attendance among children with a treatment need and to examine the relative importance of screening, social class and other factors in dental attendance. METHODS: Sixty-four participating schools were assigned to study and control groups using a stratified, blocked randomisation technique. The study group children received the standard school dental screening and the dental attendance of those with a positive screening result was assessed after 2 months by means of a questionnaire issued to the children's parents. The control group children were not, at this stage, screened, yet their parents received the same questionnaire assessing dental attendance over the 2-month period. However, only questionnaires from control group children who had a positive result at a subsequent screening were retained for analysis. RESULTS: A total of 2,321 children were screened, with 980 having a positive result. The mean dmft of those screening positive was 4.85. In all, 664 completed questionnaires were returned, giving a response rate of 67.8%. Dental attendance was reported among 45.5% of the study group (n=352) in the 2 months following screening. In the same period, 27.6% of the control group (n=312) claimed attendance. The effect was found to be significant among the high employed group (P<0.01) and the unemployed group (P<0.05). CONCLUSION: School dental screening was capable of stimulating dental attendance. The strong effect among the lowest socio-economic group shows that school dental screening may be used to decrease dental health inequalities.

A study in two centres of variations in the time of apical barrier detection and barrier position in nonvital immature permanent incisors.

OBJECTIVES: To study barrier formation in nonvital, immature permanent incisors being treated using the apexification technique in two centres, and to establish the effect of the frequency of change of calcium hydroxide (CaOH) on barrier detection times. DESIGN: A retrospective study of the time of detection and the position of barriers. RESULTS: There were no significant differences between the two centres in terms of the average frequency of change of each CaOH dressing, the distribution of barrier detection times or the position of barriers (P > 0.05). There was a total of 107 teeth and the time of barrier detection was significantly earlier in more frequently dressed teeth (P = 0.013). Of the teeth with a barrier detection time of less than 9 months, 60.7% were dressed more frequently than every 3 months, as opposed to 39.1% of teeth with longer barrier times (P = 0.027). The mean time of barrier detection for all cases was 43.3 weeks. The majority of barriers were located at or near the apex. CONCLUSION: The frequency of change of CaOH can increase the speed of barrier detection but does not appear to affect the position.

Variations in the presenting and treatment features in reimplanted permanent incisors in children and their effect on the prevalence of root resorption.

OBJECTIVE: To examine variations in the presentation and treatment of reimplanted incisors in children and to determine the effect of these on the prevalence of external root resorption. SETTING: Departments of Paediatric Dentistry, Belfast and Newcastle upon Tyne. DESIGN: Recording of the timing of the injury and the storage mediums (including air) and of reimplantation, the stage of root development, the degree of contamination and the time of commencement of root treatment. Cases were reviewed clinically and radiographically at intervals of 3 months. Root resorption was classified as present or absent. Logistic regression and cross-tabulations were produced with the presence of resorption set as the outcome. RESULTS: 128 reimplanted permanent incisor teeth, their median dry time prior to reimplantation being 15 minutes (range 4-52 mins), the median time in a liquid medium being 45 minutes (range 0-650 mins), with a median splinting time of 15 days (range 4-52 days) and a median pulp extirpation time of 15 days (range 0-612 days). There was a lower prevalence of resorption when the period of dryness was less than or equal to 5 minutes (p = 0.025). The prevalence of resorption in teeth with no visible contamination was 57.1%, for those with contamination which were washed clean it was 75%, in those rubbed clean it was 87.5%, and it was 100% for those reimplanted with visible contamination still present (p = 0.014). The corrected odds ratio for contamination was 2.99 and for an extension of 10 minutes of dryness it was 1.29. CONCLUSION: The degree of contamination and the period of dryness were the major risk factors for resorption in this study of reimplanted teeth in children.

Acute confusion secondary to pneumocephalus in an elderly patient.

PRESENTATION: an 83-year-old man was admitted to hospital with acute confusion 3 days after a direct flight from Australia. OUTCOME: computed tomography (CT) brain scan and magnetic resonance imaging head scan revealed the cause to be pneumocephalus, apparently the result of barotrauma caused by Valsalva manoeuvres when he attempted to unblock his nose during the flight. After 5 days of nursing in the vertical position the patient's Abbreviated Mental Score returned to normal. A CT brain scan 6 weeks later showed complete resolution of the pneumocephalus.