Sealing Occlusal Dentin Caries in Permanent Molars: 7-Year Results of a Randomized Controlled Trial.

The purpose of this study was to investigate the possibility of postponing restorative intervention of manifest occlusal caries in young, permanent dentition by non-invasive sealing. This RCT-designed study included 521 occlusal lesions in 521 patients aged 6 to 17 y. Based on clinical and radiographic assessments, all lesions required restorative treatment. After randomization (ratio 2:1), 368 resin sealings and 153 composite-resin restorations were performed by 68 dentists in 9 municipalities. The primary aims were to 1) analyze survival of sealings until replacement by restoration, 2) compare longevity of sealings and restorations until retreatments, and 3) compare effectiveness of sealings and restorations to halt caries progression in sealed lesions and beneath restorations. Furthermore, we aimed to identify factors influencing longevity and the effectiveness of sealings and restorations. Treatments were annually controlled, clinically and radiographically. After 7 y, the drop out rate was 8%, and 54% of the treatments were completed due to age. Of the sealings, 48% were retreated, including 31% replaced by restorations; 12% were still functioning. Of the restorations, 7% were repaired/renewed and 20% were still functioning. No endodontics was performed. Kaplan-Meier and Cox regression survival analyses were performed on 341 sealings and 152 restorations in first and second molar teeth. The 7-y survival was 37% (CI, 29% to 45%) for sealings and 91% (CI, 85% to 96%) for restorations (P < 0.001). The median survival time for sealings not replaced by restorations was 7.3 y (CI, 6.4 y to NA). Survival of sealings was increased in patients with low caries risk and/or excellent oral hygiene, second molars compared with first molars, and lesions not extending the middle one-third of the dentin. Survival of sealings was not influenced by municipality, sex, eruption stage or clinical surface cavitation. The results underline that it is possible to postpone or avoid restorative intervention of occlusal dentin caries lesions in young permanent teeth by non-invasive sealing. Knowledge Transfer Statement: The first restoration can ultimately be fatal for a young permanent tooth. A restoration may not be the final treatment but the start of an ongoing treatment with still more loss of tooth substance. The present study shows the possibility of treating occlusal dentin caries lesions with non-invasive resin sealings instead of conventional resin composite restorations in children and adolescents. Improved oral health can be expected.

Therapeutic and economic implications of traumatic dental injuries in Denmark: an estimate based on 7549 patients treated at a major trauma centre.

AIM: To analyse the type and extent of injuries presented by patients seeking treatment for traumatic dental injuries at a major trauma centre. Furthermore, to analyse acute and subsequent treatment demands and treatment costs. METHODS: A therapeutic and economic analysis was performed of 7549 patients treated for traumatic dental injuries in a major trauma centre located at the University Hospital in Copenhagen, Denmark. Cases were divided into uncomplicated (concussion, subluxation, enamel and enamel-dentine fractures) and complicated cases (crown fractures with exposed pulps and crown-root fractures, luxation injuries with displacement of the tooth and bone fractures). RESULTS: Primary tooth injuries were found in 2874 patients, involving 5443 teeth, among which 62.8% had complicated injuries. Permanent tooth injuries were found in 4525 patients, involving 10,673 teeth, among which 40.4% had complicated injuries. The cost of treatment (including acute trauma service, follow-up and subsequent restoration) was estimated to be 0.6-1 mill USD a year for the patients treated in this trauma centre. If this figure is transferred to the estimated trauma population in Denmark, a yearly cost of traumatic dental injuries appears to range from 2 to 5 mill USD per 1 mill inhabitants per year according to the treatment scenario. CONCLUSION: Thus, treatment of traumatic dental injuries comprises an expensive part of the health services in Denmark.

Healing of 208 intra-alveolar root fractures in patients aged 7-17 years.

This retrospective study consisted of 208 root-fractured, 168 splinted and 40 not splinted incisors in young individuals (aged 7-17 years) treated in the period 1959-1973 at the Pedodontic Department, Eastman Institute, Stockholm. Clinical and radiographic analyses showed that 69 teeth (33%) had developed hard tissue (fusion) healing of fragments. Interposition of periodontal ligament (PDL) and bone between the fragments was found in 17 teeth (8%). Interposition of PDL alone was found in 74 teeth (36%). Finally, non-healing with pulp necrosis and inflammatory changes between fragments was seen in 48 teeth (23%). Various clinical factors were analyzed for their relationship to the healing outcome with respect to healing/no healing and type of healing (hard tissue versus interposition of bone and/or PDL). Immature root and positive pulp sensitivity at time of injury was found to be significantly related to both pulp healing and hard tissue repair of the fracture. The same applied to concussion or subluxation of the coronal fragment compared to luxation with displacement (extrusive or lateral luxation). This relation was also represented by the variable millimeter diastasis between fragments before and after repositioning. Repositioning appeared to enhance the likelihood of both pulp healing and hard tissue repair. A positive effect of splinting, splinting methods (cap splints or orthodontic bands with an arch wire) or splinting periods could not be demonstrated on either pulp healing or type of healing (hard tissue versus interposition of bone and/or PDL). In conclusion, the findings from this retrospective study have cast doubts on the efficacy of long-term splinting and the types of splint used for root fracture healing. It is suggested that the role of splinting and splinting methods be examined in further studies.

Infraposition of ankylosed permanent maxillary incisors after replantation related to age and sex.

The extent of infraposition of replanted and subsequently ankylosed permanent incisors was examined in a longitudinal study of 52 patients. Study cast models were made during the follow-up period. Infraposition was evaluated on frontal photos of the study cast models taken parallel with the occlusal plane. The extent of infraposition was defined as the difference between the position of the incisal edge of the replanted incisor and the adjacent non-injured incisor in apico-coronal direction, measured with a digital caliper at 50x magnification of the negatives. The precision of this measuring procedure was 2.9% and the accuracy 2.0%. Marked infraposition was identified if the tooth was traumatized before the age of 16 in boys and before the age of 14 in girls. In addition, infraposition was observed when ankylosis developed in patients aged 20-30 years, with a yearly mean infraposition rate of 0.07 mm/year (range: 0.02-0.21 mm/year) in males and 0.07 mm/year (range: 0.00-0.12 mm/year) in females. The latter findings supported the concept of slow continuous eruption of the teeth. This phenomenon may have implications not only for the treatment of traumatized teeth but also for the treatment of tooth loss by osseointegrated implants, which represent an analogue to the ankylosed replanted tooth.

Sequelae of trauma to primary maxillary incisors. I. Complications in the primary dentition.

Two hundred and eighty-seven children with a total of 545 traumatized primary upper incisors were followed using standardized procedures until the age of 10. Extraction was the only treatment offered when intervention was necessary. The immediate as well as the long-term consequences of trauma were studied on the basis of this material. Consequences in the primary dentition comprised: color changes (53%), pulp necrosis (25%), pulp canal obliteration (36%), gingival retraction (6%), permanent displacement after luxation (5-22%), pathological root resorption (1-10%) as well as disturbances in physiological root resorption (4%) and, lastly, premature tooth loss (46%). In a multivariate analysis of the development of pulp necross in primary teeth after trauma, the following decisive factors were found: age of the patient at the time of injury, degree of displacement of the tooth as well as the degree of loosening and presence of crown fracture. The factors found to influence development of pulp canal obliteration were: displacement of the tooth at time of injury as well as detectable physiologic root resorption at time of trauma. The presence of crown fracture seemed to decrease the risk of obliteration. The need for scientifically based treatment strategies for managing and reducting complications after trauma in the primary dentition is stressed.

Replantation of 400 avulsed permanent incisors. 1. Diagnosis of healing complications.

A material of 322 patients with 400 avulsed and replanted permanent teeth were followed prospectively in the period from 1965 to 1988 (mean observation period = 5.1 yrs). The age of the patients at the time of replantation ranged from 5 to 52 yrs (mean = 13.7 yrs and median = 11.0 yrs). Standardized patient records were used through the entire period in order to obtain valid data concerning the extent of injury and treatment provided. At the follow-up period, pulpal and periodontal healing were monitored by clinical examination, mobility testing and standardized radiographic controls. Thirty-two of the replanted teeth (8%) showed pulpal healing. When related to teeth with incomplete root formation, where pulpal revascularization was anticipated (n = 94) the frequency of pulpal healing was 34%. Periodontal ligament healing (i.e. with no evidence of external root resorption) was found in 96 teeth (24%). Gingival healing was found in 371 teeth (93%). During the observation period, 119 teeth (30%) were extracted. Tooth loss was slightly more frequent in teeth with incomplete root formation at the time of replantation than in teeth with completed root formation.

Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing.

Four hundred avulsed and replanted permanent teeth were examined for pulpal healing. In 110 teeth, the apical foramen was either open or half-open. In 16 teeth, the pulps were extirpated prophylactically. Thus, pulpal revascularization was considered possible in 94 teeth. Revascularization occurred in 32 teeth (34%). Pulp necrosis could usually be demonstrated after 3 weeks. Positive pulpal sensibility and radiographis signs of pulp canal obliteration were usually observed after 6 months. The effect of various clinical factors was examined, such as sex, age, type of tooth replanted, stage of root formation, type and length of extra-alveolar storage, clinical contamination of the root surface, type of cleansing procedure of the root surface, type and length of splinting and the use of antibiotics. Finally, the width of the apical foramen and the length of the root canal were measured on radiographs taken at the time of injury. A multivariate statistical analysis revealed that pulpal revascularization was more frequent in teeth with shorter distances from the apical foramen to the pulp horns. Furthermore, that wet storage (saliva and/or saline) for more than 5 min decreased the chance of pulpal revascularization; whereas dry extraalveolar storage had a monotonous effect on pulpal revascularization, i.e. decreasing chance of revasculatization with increasing length of the extraalveolar dry storage. Based on these findings, immediate replantation after brief cleansing in either tap water or saline is recommended.

Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth.

Four hundred avulsed and replanted permanent incisors were examined for pulpal and periodontal healing. In 30 teeth, root formation was incomplete at the time of injury. Two teeth were excluded from the study due to nonphysiological extraalveolar storage (i.e. homemade saline). Of the 28 remaining replanted incisors, 7 showed subsequently completed root development, 8 partially completed root development and 13 arrested root development. Completed root development subsequent to replantation was found to be significantly related to pulpal revascularization, being rare in cases with pulp necrosis (5 of 15 teeth) and frequent after pulpal healing (11 of 13 teeth) (p = 0.01). Root development was not found to be significantly related to the extraalveolar storage period; but occurred slightly more frequently when the dry storage period was less than 45 min. (p = 0.13). Ingrowth of bone and formation of an internal periodontal ligament (PDL) was found in 6 teeth and was related to arrested root formation in cases with pulpal healing. The explanatory factor for these findings appeared to be damage to the Hertwig's epithelial root sheath.

Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing.

400 avulsed and replanted permanent teeth were examined for periodontal ligament (PDL) healing, using standardized radiographic and clinical examination procedures (i.e. percussion test and mobility test). The effect of various clinical factors was examined, such as age and sex of the patient, type of tooth replanted, presence of crown fracture or bone fracture, stage of root development (including apical diameter and length of the pulp), type and length of extra-alveolar storage, clinical contamination of the root surface, type of root surface cleansing procedure, type and length of splinting period and antibiotic therapy. Surface resorption was generally diagnosed after 12 months; while inflammatory resorption and replacement resorption (ankylosis) were usually observed after 1 month and 1-2 months respectively. Most resorptive processes were diagnosed within the first 2-3 years. However, although rarely, even after 5 and 10 years new resorptive processes could be diagnosed. A univariate statistical analysis of 272 teeth revealed 9 factors significantly related to PDL healing. A subsequent multivariate analysis revealed that the following 4 factors had the strongest impact upon PDL healing, in descending order of significance: Stage of root development; length of the dry extra-alveolar storage period; immediate replantation and length of the wet period (saliva or saline storage). Nonphysiological storage, such as homemade saline and sterilizing solutions (chloramine and alcohol) always led to root resorption. Storage in tap water for more than 20 minutes usually led to root resorption. The common denominator for all these factors related to PDL healing appears to be survival of the PDL cells along the root surface. Based on these findings, immediate replantation is recommended irrespective of stage of root development.