Regenerative endodontic therapy: a follow-up of 47 anterior traumatised teeth.

PURPOSE: To collect long-term survival data in anterior traumatised teeth on the outcome of Regenerative Endodontic Treatments (RET) with a network of dentists working in different clinics to overcome the problem of anecdotical evidence. METHODS: The seven dentists from Paediatric REsearch Project (PREP) performed RET treatments following the same protocol in five different secondary dental care clinics in the Netherlands. Treatment resulting in pain, apical problems, sinus tracts, resorption or fracture were considered as failure of treatment. RESULTS: 47 teeth in 38 children were treated between January 2009 and September 2017 and had at least 6 month follow-up (mean 35 months). Apical closure was seen in 27 teeth (25 cases) and root length growth in 6 teeth (6 cases). Thickening of the root walls was seen in 20 teeth (20 cases) and obliteration of the root canal in 30 teeth (25 cases). Of 38 teeth with apical inflammation at the start of treatment, no radiographic sign of apical inflammation was visible at 3 months in 13 of 28 teeth; taking up to 42 months for radiographic signs of apical inflammation to be not visible. Nineteen of 35 teeth showed discoloration at the beginning of treatment. After 18 months two teeth showed signs of ankylosis, but were still functional. After 36 months one more tooth showed signs of new apical inflammation and 2 months later it was extracted. CONCLUSIONS: With three failures in 47 treated teeth, RET seems to be a promising treatment for difficult to treat anterior traumatised teeth with an open apex.

Barriers and opportunities to oral health in Dutch-Moroccan children in the Netherlands: a narrative report.

INTRODUCTION: Previous studies showed that 5-year-old Dutch-Moroccan children had significantly higher dmft scores compared to Dutch children of the same age, even after correction for socio-economic status. The mechanisms underlying this difference are little understood. AIM: To explore cultural factors involved in poorer oral health of Dutch-Moroccan children by identifying knowledge, attitudes and behaviour of their mothers concerning their children's oral health. METHODS: In 2012 mothers of Dutch-Moroccan preschool children in two cities in the Netherlands were interviewed in two focus groups (n = 16) or individual semi-structured interviews (n = 13). Semi structured interviews were also c onducted with three oral health professionals, working with Dutch-Moroccan children, and one physician from an under-five-clinic. All interviews were voice recorded, transcribed and inductively coded. MAXQDA software was used for data analysis. RESULTS: All mothers mentioned pain complaints, swelling and black front teeth as oral health problems in their children. Although mothers were aware that brushing teeth and reducing sugary snacks are effective preventative strategies, they did not sufficiently implement these measures. This was due to lack of brushing skills, insufficient awareness of the daily sugar intake of their children and their childrearing concerning these measures. Most mothers indicated they felt empowered in making dental care decisions. CONCLUSIONS: This research revealed the presence of knowledge on preventive strategies regarding their children's oral health in Dutch-Moroccan mothers, but an inadequate implementation of these measures in their daily lives. Additional qualitative research is needed to gain deeper insight for broader exposure of values, knowledge and culture.

Association between Bone Mass and Dental Hypomineralization.

The aim of this study was to examine the association between the bone mass (bone mineral content [BMC]) and hypomineralized second primary molars (HSPMs)/molar incisor hypomineralization (MIH) in 6-y-old children. This cross-sectional study was embedded in the Generation R Study, a population-based prospective cohort study, starting from fetal life until adulthood in Rotterdam, Netherlands. The European Academy of Pediatric Dentistry criteria were used to score the intraoral photographs on the presence or absence of HSPMs and MIH. Bone mass was measured with a dual-energy x-ray absorptiometry (DXA) scan. Intraoral photographs and DXA scans were available in 6,510 6-y-old children. Binary logistic regression models were used to study the association between the bone mass and HSPMs/MIH. In total, 5,586 children had their second primary molars assessed and a DXA scan made; 507 children were diagnosed with HSPM. Of 2,370 children with data on their permanent first molars, 203 were diagnosed with MIH. In the fully adjusted model, children with lower BMC (corrected for bone area) were more likely to have HSPMs (odds ratio, 1.13; 95% confidence interval, 1.02 to 1.26 per 1-standard deviation decrease). A lower BMC (corrected for bone area) was not associated with MIH (odds ratio, 1.02; 95% confidence interval, 0.87 to 1.20 per 1-standard deviation decrease). We observed a negative association between BMC (corrected for bone area) and HSPMs. No association was found between BMC (corrected for bone area) and MIH. Future research should focus on investigating the mechanism underlying the negative association between the bone mass and HSPMs. Our study, in a large population of 6-y-old children, adds the finding that BMC (corrected for bone size) is associated with HSPMs but not with MIH in childhood.

Mineral content in teeth with deciduous molar hypomineralisation (DMH).

OBJECTIVES: We report the mineral (hydroxyapatite) density of sound and opaque areas in DMH molars with sound parts of (carious) deciduous teeth serving as controls. METHODS: Twenty-nine extracted second primary molars obtained from 15 children were studied. Thirteen of these molars were DMH molars with yellow opacities, seven were DMH molars with white opacities, three DMH molars with brown opacities and eleven were molars without DMH. Prior to microCT scanning, the teeth were mounted in impression material (Impregum(®)) and stored in water with a thymol crystal. Spot analysis and line scans were performed in areas with opacities and in sound areas. An ANOVA test and t-tests were used to test if there were significant differences between the groups. RESULTS: The average densities of the hydroxyapatite in yellow and brown opacities (1368mg HA/cm(2) and 1407mg HA/cm(2), respectively) were significantly lower than in clinically unaffected enamel (1747mg HA/cm(2)) of DMH molars or of sound molars (1758mg HA/cm(2)). The mineral density in white opacities (1737mg HA/cm(2)) was not different from that in the enamel of sound molars. The mineral density values in yellow and brown enamel opacities were in between those of dentine (1018mg HA/cm(2)) and enamel. CONCLUSIONS: DMH molars with yellow or brown opacities had a 20-22% lower mineral density in the hypomineralised enamel compared with sound molars. White opacities do not show a lower mineral content. The reduction in enamel mineral content in DMH molars stressed the need for a preventive approach in DMH.

Pain-related behaviour in children: a randomised study during two sequential dental visits.

AIM: To determine the difference in pain- and distress-related behaviour in children between two consecutive dental treatment sessions using a computer-controlled local anaesthetic delivery system, with dental anxiety as co-variable. METHODS: A randomised prospective study over two sequential visits in three paediatric dental practices. For both visits 112 young, healthy children needing dental treatment were randomly assigned to either the use of the Wand(®) or the Sleeper One(®). All statistical analyses were performed using SPSS 17. A significance level of p < 0.01 was used, correcting for conducting a high number of tests. RESULTS: Children showed significantly more muscle tension, more verbal protest, and more crying or screaming during the second treatment. CONCLUSIONS: Sequential dental treatments seem to have a conditioning effect. It is important to know the level of dental anxiety to adjust the treatment sequence to the needs of the child.

Comparison of two computerised anaesthesia delivery systems: pain and pain-related behaviour in children during a dental injection.

AIM: The purpose of this study was to investigate whether there is a difference in pain and distress response of the child when using two different computer-controlled local analgesic delivery systems, the Sleeper One(®) and the WAND(®), and whether this was influenced by the anxiety level of the child. METHODS: This randomised controlled trial was conducted among 112 children (56 girls) aged 4-6 years (mean age 66 months, SD 9 months). All children needing at least one dental visit using local analgesia were randomly assigned to either the Sleeper One(®) or the WAND(®). RESULTS: During the injection phase, children expressed the same amount of disruptive behaviour using the Sleeper One(®) or the WAND(®) (Mann-Whitney U test, p > 0.05). The average injection time of the Sleeper One(®) (mean 2.49 min, SD 0.56) was significantly shorter than that of the WAND(®) (mean 3.20 min, SD 0.61; Mann-Whitney U test, p < 0.001). CONCLUSION: No significant difference was found in pain and distress reaction of the child between the WAND(®) and the Sleeper One(®). The average delivery time of the Sleeper One(®) was shorter.

Summary of: comparing the onset of maxillary infiltration local anaesthesia and pain experience using the conventional technique vs the Wand in children.

AIM: This prospective, randomised, parallel, controlled study was conducted firstly to compare the onset of local anaesthesia (LA) when using the conventional technique versus the Wand computer-controlled LA and secondly to assess the pain experience in children. METHOD: Thirty children were randomly allocated to the treatment group (Wand) or the control group (conventional). Lidocaine 2% with adrenaline (1:80,000) was given as a buccal infiltration. The onset of pulpal anaesthesia was tested using an analytic electric pulp tester (EPT). The pain experience during the LA was recorded using a modified visual analogue score (VAS). RESULTS: Median time for the onset of LA was 6.30 minutes for the control and 7.25 minutes for the Wand group. Mean pain experience score for the control group was 9.78% as opposed to 8.46% in the Wand group. Statistical analysis showed that there was no statistically significant difference in the onset of LA (p = 0.486) and the pain experience (p = 0.713) between the two groups. CONCLUSION: When placing a buccal infiltration on upper first permanent molars, the onset of LA and the pain experience was no different using the Wand and the conventional technique.

Deciduous molar hypomineralization and molar incisor hypomineralization.

This study was embedded in the Generation R Study, a population-based prospective cohort study from fetal life until young adulthood. This study focused on the relationship between Deciduous Molar Hypomineralization (DMH) and Molar Incisor Hypomineralization (MIH). First permanent molars develop during a period similar to that of second primary molars, with possible comparable risk factors for hypomineralization. Children with DMH have a greater risk of developing MIH. Clinical photographs of clean, moist teeth were taken with an intra-oral camera in 6,161 children (49.8% girls; mean age 74.3 mos, SD ± 5.8). First permanent molars and second primary molars were scored with respect to DMH or MIH. The prevalence of DMH and MIH was 9.0% and 8.7% at child level, and 4.0% and 5.4% at tooth level. The Odds Ratio for MIH based on DMH was 4.4 (95% CI, 3.1-6.4). The relationship between the occurrence of DMH and MIH suggests a shared cause and indicates that, clinically, DMH can be used as a predictor for MIH.

Differences in treatment approach between Dutch paediatric dentists and general practitioners, a case control study.

AIM: This case control study was to assess whether paediatric dentists perform significantly more diagnostic, preventive and curative care in a clinical setting then do general dental practitioners. METHODS: 16 paediatric dentists were approached and a matching control group of 16 general dental practitioners drawn from an insurance random list were selected based on matching age, practice composition and year of graduation. They were asked by mail to participate. Positive respondents were visited. All children seen during the visit were included in this study. During intra-oral inspection DMFS/dmfs was clinically scored, as were the availability of bitewings, gender, presence of fissure sealants, visibility of plaque and gingivitis and presence of fistulas. STATISTICS: Statistical analysis was carried out by using SPSS 15, p<0.05 was considered statistically significant. RESULTS: Paediatric dentists treat a greater number of younger children (p<0.05), placed more restorations and sealants (p<0.01), take more bitewing radiographs (p<0.01) and give a similar level of care to all children irrespective of their age compared to children seen by general dental practitioners. CONCLUSIONS: Paediatric dentists perform significantly more diagnostic, preventive and curative care in the clinical situation for 0-6 year old children than do general dental practitioners.

Child dental anxiety, parental rearing style and referral status of children.

OBJECTIVE: Treating children can be difficult for both dentist and child. In some cases treatment fails and those children are referred to a specialist paediatric dentist. Different factors can be put forward for referral of children, such as factors relating to the child, dentist and parent. Possible child-related factors can be dental anxiety and the child's temperament. A possible parental factor is the parental rearing style. The objective of this study was to assess the possible associations between dental anxiety, parental rearing style and referral status of children. METHODS: Parents of 120 non-referred and 335 referred paediatric dental patients were asked to fill out the Child Rearing Practices Report (CRPR) and the Child Fear Survey Schedule Dental Subscale (CFSS-DS) on behalf of their children. RESULTS: The questionnaires were filled out by 115 (96%) parents of primary schoolchildren and by 331 (99%) parents of referred children. Referred children were younger than non-referred children, t(442) = 6.9, p < 0.01, and had significantly more dental anxiety, t(430) = -8.7, p < 0.01. No differences existed between parents of referred children and parents of non-referred children on parental rearing-style. No differences existed between fearful and non-fearful children on parental rearing-style and also no correlation existed between children's dental anxiety and their parent's rearing style. However, non-referred children with parents using an authoritarian parenting style were more anxious than the other non-referred children. CONCLUSIONS: In the present study, referral status and dental anxiety of 4-12 year old children were not associated with parental rearing style.

Dental fear in children with a cleft lip and/or cleft palate.

OBJECTIVE: To assess the level of dental fear in children with a cleft lip and/or palate, to compare this level with that of a normative group testing the hypothesis that children with a cleft lip and/or palate have a higher level of dental anxiety than children from the general population, and to assess the relation between dental fear and coping. DESIGN: Cross-sectional study. SETTING: VU Medical Centre University Amsterdam. PATIENTS: A total of 110 children (4 to 12 years old, 50 girls) with a cleft lip and/or palate. INTERVENTIONS: Dental fear in the study group was compared with a normative group of Dutch children. MAIN OUTCOME MEASURES: Dental fear was investigated using the parental version of the dental subscale of the Children's Fear Survey Schedule for children aged 4 and 5 years old (n = 36). Also the Inventory of Stressful Situations was completed. Children aged 6 to 12 years old also completed the Dental Cope Questionnaire. RESULTS: Young children with a cleft lip and/or palate experience more dental fear compared with children in a normative control group (Children's Fear Survey Schedule dental subscale scores: 30.3 ± 14.6 compared with 24.6 ± 8.6, p < .01). A weak correlation was found between the child's dental anxiety (Children's Fear Survey Schedule dental subscale) and his or her coping behavior (Dental Coping Questionnaire) (r = .196 p < .05). A clear correlation exists between the total Inventory of Stressful Situations and total Children's Fear Survey Schedule scores of the youngest age group (r = .507 p < .01). CONCLUSIONS: Findings support the hypothesis that dental anxiety is related to a higher level of exposure to medical interventions at a young age.

Influence of parental presence on the child's perception of, and behaviour, during dental treatment.

AIM: To analyse the influence of the presence of the parent in the dental operatory on their child's behaviour during dental treatment. METHODS: This study was a randomised controlled trial performed in a secondary paediatric dental care clinic. The child's perception of the dental treatment and its behaviour during treatment according to the parent and dentist were compared with parental presence in the operatory as independent variable. Age and dental anxiety were also calculated as co-variable. The child's perception of the treatment was assessed using the Wong-Baker Faces Rating Scale. The behaviour of the child according to parent and dentist was measured using Venham`s (modified) clinical rating of anxiety and cooperative behaviour. Statistical analysis was performed using Mann Whitney U tests and Independent Samples T Test. RESULTS: 90 children participated (50% girls, mean age 6.21 years old, SD ± 1.56). During the habituation session child's behaviour was better according to the dentist when the parents were not present in the operatory during treatment (p<0.01). There were no significant differences in a child's perception of the treatment in relation to parental presence or absence. Dentally anxious children behaved better according to the parent (treatment session 2) and the dentist (habituation session and treatment session 2) when the parent was not present in the operatory (p<0.05). CONCLUSION: Relying on a child's perception of dental treatment, a made no difference whether the child was treated with or without the parent(s) in the dental operatory. For anxious children it was mainly the dentist who was aware of the disadvantages of the parental presence.

Child dental fear and general emotional problems: a pilot study.

AIM: This was to investigate the relation between general emotional and behavioural problems of the child and dental anxiety and dental behavioural management problems. BACKGROUND: Dental treatment involves many potentially unpleasant stimuli, which all may lead to the development of dental anxiety and behavioural management problems (BMP). It is still unclear why some children get anxious in the dental situation while others, with a comparable dental history, do not. Besides the latent inhibition theory it is suggested that this can be explained by differences in child rearing and personality traits. METHODS: The sample consisted of 50 children (4-12 years old) and their parents participated in this study. Parents filled out the Child Fear Survey Schedule Dental Subscale (CFSS-DS) and the Child Behaviour Checklist (CBCL) on behalf of their child. Child behaviour during consecutive dental treatments was assessed using the Venham scale. RESULTS: There were 39 children subject to analysis (21 boys) with a mean CFSS score of 40.4. Children aged 4 and 5 years who had sleeping problems, attention problems and aggressive behaviour, as scored by parents on the CBCL, displayed more disruptive behaviour during dental treatment. Children with emotionally/ reactive and attention problems were more anxious. CONCLUSION: In this pilot study a possible relation between general emotional and behavioural problems of young children and dental anxiety was shown. Also a relation between emotional and behavioural problems and dental behavioural management problems was shown. Because of the small number of subjects in our study, further research will be needed to confirm these results.

[Principles of oral health care for children]. / Uitgangspunten van mondzorg voor kinderen.

In this article the principles of child oral health care in the Netherlands and the consequences of cariological principals of oral health care delivery to children are described. First of all the age of the child plays a very significant role in decisions concerning prevention and restoration. In addition, the combination of a positive attitude on the part of the dentist and a pain-free treatment can prevent fear of treatment and avoidance behaviour of the children. In the treatment of carious lesions, moreover, the oral health care provider should consider to what extent the problem is related to behaviour and fits in the multi-factorial caries model. Restorative treatments should be considered as supporting prevention, reducing caries activity and eliminating the effects of neglected oral health care. Prevention has to be seen as an essential element of the treatment model and it should start early from the standpoint of habit formation and the rapid demineralization process in the deciduous dentition which results from failed preventive care.

[Tooth development disturbances following haematopoietic stem cell transplantation]. / Langetermijneffecten op de gebitsontwikkeling na stamceltransplantatie.

Forty children treated with allogenic haematopoietic stem cell transplantation for haematological malignancies, were examined at least 2 years after transplantation. The researchers collected information concerning subjective oral symptoms, the results of a panoramic radiograph and the findings of an oral examination. Nearly all children had tooth development disturbances, including missing teeth, shortened roots, and arrested root development. The study group showed a significantly higher prevalence of missing teeth than the standard values for first and second premolars in both maxilla and mandible, as well as for second molars in the mandible. Children younger than 3 years of age at the start of the treatment missed significantly more teeth than older children. The mean root-crown length ratios of several tooth types were lower when compared with a control group of healthy Finnish children. The mean dental age was higher than the mean chronological age due to early final apical root formation.

A comparison of paediatric dentists' and general dental practitioners' care patterns in paediatric dental care.

AIM: The aim of this study was to compare the care patterns of paediatric dentists and general dentists in the dental treatment of children in the Netherlands. STUDY DESIGN AND METHODS: A case control study was completed based on the financial records of one of the largest Dutch health insurance companies. After medical ethical approval the dental records from 2004, 2005 and 2006 of 16 paediatric dentists were used and compared with the records of general practitioners with the same number of insured paediatric patients from the same age and urbanisation level. Preventive, diagnostic and restorative care for four consecutive age groups (<6, 6-8, 9-11, 12-17 yrs) were used as independent variables. Differences between the dentists and the age groups were tested with the Independent-Sample t-Test and ratios were calculated. RESULTS: Compared with general dentists, paediatric dentists use statistically significant more often rubber-dam (p=0.009) and did more preventive treatments (p<0.001) in children up to aged 11 yrs, more extractions (p<0.001), took more radiographs (p=0.027) and used local analgesia more often (p=0.002) in children until aged 8 yrs and performed more restorations (p=0.02) in children up to 6 yrs of age. There was no significant difference in the care pattern of the dentists for the oldest age group (12-17 yrs). The care-index for paediatric dentists and general dentists from this research was comparable with Dutch epidemiological studies. CONCLUSION: Compared with general dentists, paediatric dentists have a more extensive treatment approach when treating children. In the youngest age groups the differences are the most pronounced. Further studies are needed to clarify whether the cause is the needs of the patient or an attitude of supervised neglect by the general dentists.

Validity of scoring caries and primary molar hypomineralization (DMH) on intraoral photographs.

AIM: The aims of this study were to assess whether intraoral photographs could be used to score caries and hypomineralization on primary molars (Using adapted Molar Incisor Hypomineralization (MIH)-criteria), and also to assess the reliability and validity in 3-7 year-old Dutch children of these scores by comparing them to direct clinical scorings. STUDY DESIGN: Cross-sectional study. METHODS: In this study 62 children (38.7% girls) with a mean age of 4.96 years (SD 1.27) participated. The children were rated clinically by their own dentist (authors JV or ME) for caries reaching the dentine in their primary molars (WHO criteria) and also for primary molar hypomineralization using the adapted MIH-criteria. For the intraoral photographs, a digital intraoral camera was used. The two paediatric dentists rated all the intraoral photographs on caries and hypomineralizations on the second primary molars, using the same criteria for the clinical scoring as for the scoring of the photographs. They scored independently, at least 2 weeks after the initial clinical scoring to avoid observational bias with the clinical scoring. STATISTICS: This clinical observation was used as the gold standard from which sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and the Positive and Negative Likelihood Ratio were computed. To test the intra-observer agreement 25 % of the photographs were scored again, at least 2 weeks after the initial scoring of the images. Inter- and intra-observer agreement were tested using Cohen's Kappa. RESULTS: The mean prevalence of clinically detected caries at tooth level was 46.7% and the mean prevalence of clinically detected hypomineralizations in second primary molars at tooth level was 21.8%. The sensitivity of assessing caries using intraoral photographs was 85.5%, the specificity 83.6%, the positive likelihood ratio 5.2 and the negative likelihood ratio was 0.17. For Primary Molar Hypomineralization (DMH) the sensitivity was 72.3%, the specificity 92.8%, the positive likelihood ratio 10.1 and the negative likelihood ratio was 0.30. The inter-observer agreement yielded the following Cohen's Kappa scores: for caries 0.76 and for DMH 0.62. The intra-observer agreement was for caries 0.80 (ME) and 0.72 (JV) and for DMH 0.95 (both ME and JV). CONCLUSIONS: From this investigation it was concluded that the sensitivity, specificity and the likelihood ratio of scoring caries and DMH on photographs made with an intraoral camera were good. The inter- and intra-observer reliability for caries and DMH were good to excellent. These findings suggest that intraoral photographs may be used in clinical practice and large epidemiological studies.

[Diagnostic and restorative behaviour in Dutch dentists' paediatric dental care]. / Diagnostisch en restauratief gedrag van Nederlandse tandartsen in de kindertandheelkunde.

The aim of this study was to determine what the approach of Dutch dentists is in the treatment of children. Prevention, X-ray diagnostics and restorative care were compared in four consecutive age groups (< 6 years old, 6-8, 9-11, 12-17 years). The insurance claims of 4550 dentists over a period of 3 consecutive years were studied. The findings showed that dentists who made use of X-rays and provided restorative care for children younger than 6 also provided restorative care for subsequent age groups on average 1.4-2.9, 1.3-2.5 and 1.2-1.8 times more than, respectively, dentists who did not make use of X-rays but did provide restorative care for children under 6 and dentists who neither made use of X-rays nor provided restorative care for children under 6. The first group of dentists also made more use of X-rays in the subsequent age groups: 3.7, 3.4 and 1.9 times respectively. On the basis of these results it can be concluded that starting restorative treatment and the use of X-rays for children younger than 6 is predictive for the quantity of care provided by dentists for the older groups of children.

The Dental Discomfort Questionnaire: the basis of a 'Toothache Traffic Light'.

AIM: Firstly to provide an overview of the combined results of the studies done with the Dental Discomfort Questionnaires (DDQ) and second to present a behaviour checklist, a 'Toothache Traffic Light', based on the DDQ, which could possibly be used to raise awareness for toothache among parents and healthcare providers and to improve communication. METHODS: A total of 652 DDQ were analysed to compare the prevalence of toothache related behaviours between children without caries, children with caries but without toothache, and children with caries and toothache. The children had a mean age of 44.6 months (SD+/-10.9). STATISTICS: Chi-square tests were conducted to compare the items of the DDQ between the three groups and predictors of toothache were determined using a binary logistic regression analysis. RESULTS: All items of the DDQ were displayed more often by the children with caries and toothache than by children with only caries or without both caries or toothache. The behaviours: "Reaching for the cheek while eating", "Pushing away something nice to eat", "Problems brushing upper or lower teeth" and "Problems chewing" were found to be the most indicative for the presence of toothache. Finally, 7 toothache related behaviours were combined in the checklist. Using the results of this survey the 'Toothache Traffic Light' was developed as a possible tool for determining toothache in very young children. CONCLUSIONS: All behaviours together could form a checklist that can possibly teach parents, guardians and teachers which behaviours to look for when they suspect a child to have toothache.