General dentists' perceptions and clinical management of hypomineralised second primary molars (HSPM) in Ireland.

PURPOSE: This questionnaire aimed to explore how general dentists in the Republic of Ireland perceive and manage hypomineralised second primary molars (HSPM). METHODS: Following ethical approval, a validated structured questionnaire containing 19 questions was sent to Irish dentists using Survey Monkey. Questions on awareness, dentist's experience, barriers to care and clinical scenarios with different treatment options were included. Binary outcomes and independent variables were compared using logistic regression analysis (α = 5%). RESULTS: Responses from 279 general dentists were analysed. The majority of dentists were aware of HSPM (72%) and most dentists felt confident in diagnosing HSPM (71%). Dentists who had practiced for ≥ 15 years were significantly more likely to document HSPM frequently compared to those with less experience (OR 0.29; p = 0.012). No significant association was found between confidence in HSPM diagnosis and other variables, such as age group, years of practice and workplace. Dentists not working in private practice reported to be less comfortable in the management of HSPM (OR 0.49; p = 0.030). The most cited barrier to management of HSPM was child's behaviour. A broad variation was observed in the clinical scenarios, in particular when treatment planning more severe HSPM. CONCLUSIONS: In general, Irish dentists are aware of HSPM and are confident in diagnosis and management. Variation existed in treatment options reflecting the disparity that exists in clinical management.

Assessment of occlusion after placement of stainless steel crowns in children - a pilot study.

Many stainless steel crowns (SSCs) disrupt the occlusion in children, but stabilisation appears to occur within a short period post-placement. The extent and mechanism of these short-term occlusal changes in children are unknown. This study sought to determine whether placement of a SSC changes the maximum intercuspation position (MIP) in children, whether the MIP returns to normal within 4 weeks and whether local anaesthesia had an effect on the child's ability to achieve MIP. The T-Scan(®) III was used for the measurement of occlusal contacts. Reliability and reproducibility of the system was determined using a calibration exercise where MIP recordings were taken of eleven children not undergoing any dental treatment. For the main study, the percentage of total occlusal force on each tooth was recorded in 20 children preoperatively, after local anaesthesia, after SSC placement and 4 weeks postoperatively. There was no significant difference in MIP (P = 0·435) preoperatively and post-administration of local anaesthesia. There was a significant difference between the preoperative force on a tooth and the reading after crown placement (P = 0·0013, Wilcoxon test). By 4 weeks, there was no significant difference overall between post-SSC placement and the preoperative value for the tooth (P = 0·3). Administration of local anaesthesia did not affect the ability of a child to attain MIP. Maximum intercuspation position was disturbed by the placement of a SSC in seven of 20 cases. When MIP was disturbed, in most cases, it returned to preoperative status within 4 weeks of crown placement.

A foreign body in disguise.

BACKGROUND: Young children habitually place objects in their mouths to discover and learn about the world and it is considered a normal stage of early childhood development. Ingestion and aspiration of foreign objects predominantly occurs in preschool toddlers with a peak incidence at age three years, and can have serious consequences. CASE REPORT: A 2-year-old boy presented to the Dublin Dental University Hospital with a tooth-coloured mass tightly adherent to a lower primary incisor. The lesion surrounded the cervical third of the crown on the lower right primary central incisor and extended subgingivally. The tooth was mobile but with minimal inflammation. TREATMENT: The tooth was subsequently extracted under general anaesthesia to reveal that the mass was in fact a foreign body, although this was originally thought unlikely as a cause. FOLLOW-UP: The patient underwent an unremarkable recovery. CONCLUSION: The case of a foreign body disguised as a tooth-like abnormality was only identified under general anaesthesia, and even then it was impossible to prise the object from the tooth in situ. Misdiagnosis of impacted foreign bodies in young children presents complicated diagnostic problems.

Articaine use in children: a review.

BACKGROUND: Lidocaine has been considered the gold standard for local analgesia agents in dentistry for years. Articaine is now widely used but there has been a reluctance to use it in children. REVIEW: Compared with lidocaine, articaine is 1.5 times as potent and only 0.6 times as toxic and has been shown to be superior in achieving successful anaesthesia following infiltration. The use of inferior alveolar nerve blocks (IANB) can be almost eliminated in children by using articaine due to its ability to effectively anaesthetic teeth up to the first permanent molar region. In addition, diffusion of the anaesthetic agent onto the palatal surface may also eliminate the discomfort of palatal infiltration. Soft tissue analgesia may be prolonged, but the risk of other adverse reactions is similar to other local anaesthetic agents. CONCLUSION: The use of articaine achieves successful pain control while reducing the volume administered and is advocated as a safe and effective alternative to lidocaine for use in children.

Case report: pre-eruptive intra-coronal radiolucencies revisited.

AIM: Pre-eruptive intra-coronal radiolucency (PEIR) describes a radiolucent lesion located in the coronal dentine, just beneath the enamel-dentine junction of unerupted teeth. The prevalence of this lesion varies depending on the type and quality of radiographic exposure and age of patients used for assessment. The aetiology of pre-eruptive intra-coronal radiolucent lesions is not fully understood, but published clinical and histological evidence suggest that these lesions are resorptive in nature. Issues around the diagnosis, treatment planning and clinical management of this lesion are explored using previously unreported cases. CASE REPORTS: Case 1: A ten-year-old girl attended for a routine check-up. An intra-coronal radiolucency in the unerupted lower right second premolar was an incidental finding on orthopantomograph (OPT). The tooth erupted and removal of enamel revealed a space filled with soft red tissue, unlike carious dentine in appearance. The tooth was restored with an indirect pulp cap, resin modified glass ionomer base and composite resin. Tissue from the lesion was removed for histopathological investigation. Root development continued to completion and the tooth remained asymptomatic and vital. Case 2: A six-year-old girl attended for her first dental visit. An intra-coronal radiolucency in a lower right first permanent molar was noted on baseline bitewing radiographs. The lesion was monitored and fissured sealed upon eruption. The lesion was monitored annually radiographically. The tooth remained symptom free for 5 years. The patient presented on an emergency basis having fractured the distolingual cusp overlying the lesion. There was no pain and the tooth was vital. The softened dentine was removed and the tooth was restored using a preformed metal crown. Case 3: A 12-year-old girl was referred for restoration of mandibular left second permanent molar. Clinically there was extensive occlusal destruction. Review of a previous OPT showed that an intra-coronal radiolucency was present in tooth 37 at least one year prior to its eruption. The large mass of coronal soft tissue was removed, the remaining enamel shell was deemed to be unrestoreable and the tooth was extracted. The patient was referred back to an orthodontist for completion of orthodontic treatment. CONCLUSION: Early detection and classification of the PEIR lesion allows an array of individualised treatments to be provided for successful outcome.

Oral health of children born small for gestational age.

We sought to evaluate the oral health status of children born small for gestational age (SGA). Children now aged 4-8 years who were born SGA (birth weight < -2 SDS) were examined using standardised criteria. The parents completed a structured oral health questionnaire. Twenty females and 25 males, mean age 72.1 months, and mean birth weight 2.1 kg, participated in the study. Poor appetite was a concern; 32 (71%) children snacked between meals and 14 (30%) used carbonated beverages more than 3 times daily. Erosion was present in 9 (20%) children. Dental decay occurred in 22 (47%) children with 92% being untreated. Eight children had more than 5 decayed teeth. It is essential that clinicians working with children born SGA include oral health within the general health surveillance and refer these children for a dental assessment within the first 2 years to support parents in establishing safe feeding patterns for their children.

Incisor reduction: a provisional aesthetic technique for traumatised teeth.

Patients in the mixed dentition who have suffered severe extrusion or avulsion injuries often present with difficult treatment decisions, especially when the initial emergency care has been compromised. Here we describe a well-tolerated, aesthetically acceptable and conservative method for treating such patients until a definitive treatment plan is possible.

Case report: Management of severe posterior open bite due to primary failure of eruption.

BACKGROUND: Primary failure of tooth eruption (PFE) is a rare condition affecting any or all posterior quadrants. Unilateral involvement of maxillary and mandibular quadrants causes a dramatic posterior open bite that requires complex management strategies. CASE REPORT: An 8 year-old boy attended the Dublin Dental School and Hospital regarding infra-occlusion of his right maxillary and mandibular primary molars. Both right first permanent molars had also failed to erupt. All permanent teeth were present radiographically. Facial appearance and soft tissues were normal and oral function was not affected. The patient had no significant medical history and his siblings had no similar dental abnormalities. TREATMENT: The infra-occluded right first and second primary molars were extracted, and the right first permanent molars were surgically exposed. FOLLOW UP: Eruption of the premolars and molars was monitored over the next 2 years. The premolars showed signs of eruption and continued root development. Exfoliation of the remaining primary teeth proceeded as usual. The right first permanent molars did not erupt and were subsequently extracted. Continued eruption of the canines and premolars reduced the inter-arch separation. A removable tongue shield appliance was suggested but declined by the patient. At age 13 years, orthodontic extrusion was used to further reduce the inter-dental distance between the canine and premolars. The reduction was from 5 mm to 1.5 mm between the right first premolars and from 10 mm to 5 mm between the right second premolars. Extrusion of the canine teeth was also attempted to improve the smile line. The canine extruded 1 mm to give a 2 mm overlap. There were no changes in centric occlusion and the midline was unaffected. In the 2 years since orthodontic treatment, the spaces have reopened slightly to 3 mm between first premolars and 6 mm between second premolars. The patient is now aged 16 years and is aware that an improved aesthetic smile line may be achieved by use of onlay restorations. CONCLUSION: In this unique case, a profound unilateral posterior open bite occurred due to primary failure of eruption of the maxillary and mandibular teeth on the affected side. Orthodontic therapy was used to modify the position of the permanent canines and premolars to reduce the posterior open bite.

Paediatric dentistry experience of the first cohort of students to graduate from Dublin Dental School and Hospital under the new curriculum.

AIM: To assess undergraduate clinical experience in Paediatric Dentistry in students graduating under a new curriculum. METHODS: An audit using logbooks completed by 34 students for all patients for whom they had provided treatment in the university paediatric dentistry clinic. RESULTS: A total of 177 child patients had received treatment from the students, age range 2-8 years. Students had performed an average of 13 restorative techniques. Sixty-eight percent had provided stainless steel crowns and 71% at least one pulpotomy for a primary tooth. All students had provided fissure sealants. Eighteen had carried out extractions and 8 had provided treatment for fractured incisors on this clinic. CONCLUSIONS: The cohort of students included had a wide range of experience of paediatric dentistry which compared favourably with accepted guidelines. A relative lack of experience of dental extractions currently remains a problem.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) targets myeloid leukocytes in the uterus during the post-mating inflammatory response in mice.

Factors in seminal plasma elicit a surge of GM-CSF expression in uterine epithelial cells after mating in mice. This study investigates the nature of the endometrial cell populations targeted by epithelial GM-CSF. In quantitative RT-PCR studies, expression of the alpha-subunit of the GM-CSF receptor (GM-CSF-R) parallelled GM-CSF expression, being maximal during the 48 h period after mating and declining thereafter. Expression of mRNA encoding beta-common chain (AIC2B) also increased after mating and remained high until the time of embryo implantation on day 4 of pregnancy. Cells expressing GM-CSF receptors were identified in sections of uterus on the day after mating using 125I-GM-CSF, and were located predominantly in the endometrial stroma subjacent to the luminal epithelium, co-localising with abundant populations of myeloid leukocytes. Cells expressing GM-CSF receptor were identified as macrophages, granulocytes and putative dendritic cells by flow cytometric analysis using lineage and receptor subunit specific antibodies. Recombinant GM-CSF injected into the uterine lumen of ovariectomised mice was found to elicit a dose-dependant accumulation of macrophages and granulocytes in the endometrium, in a pattern of distribution comparable to that seen in uteri after natural mating. Together, these data indicate a role for epithelial cell-derived GM-CSF in mediating the recruitment and potentially in modifying the behaviour of uterine leukocytes during the post-mating inflammatory response in mice.

Delayed eruption of permanent teeth in hyperimmunoglobulinemia E recurrent infection syndrome.

OBJECTIVE: To determine the incidence of abnormal tooth eruption in patients with hyperimmunoglobulinemia E (hyper-IgE) syndrome. STUDY DESIGN: This study evaluated 34 individuals with hyper-IgE syndrome (age range, 2-40 years). A comprehensive dental history and a head and neck evaluation were performed on all patients. Dental age was assessed in patients younger than 17 years by 2 methods: (1) clinical assessment of tooth eruption and (2) a radiographic method. Relationships between the chronologic age, dental developmental age, and age at tooth eruption were determined. Other oral or dental anomalies were recorded. RESULTS: Of patients older than 7 years, 75% reported problems with permanent tooth eruption, as evidenced by retained primary teeth or the need for elective extractions of primary teeth to allow eruption of permanent teeth. None of the patients experienced problems with eruption of primary teeth. Eruption of the first and second permanent molars also occurred on time. Dental maturity scores were established for 14 patients 17 years of age or younger. In each case, the difference between chronologic age and the estimated dental developmental age was less than 12 months; however, we found a significant discrepancy between the chronologic age and the mean age of tooth eruption in 80% of these patients when using a particular set of standardized values. Persistence of Hertwig's epithelial root sheath was observed on histologic examination. Chronic multifocal oral candidiasis was a consistent feature in patients with hyper-IgE recurrent infection syndrome. Other oral anomalies were also noted. CONCLUSION: We confirmed that a disorder of tooth eruption is part of the hyper-IgE syndrome. This problem occurs because of delayed primary tooth exfoliation rather than a developmental delay in the formation of the permanent dentition. The persistence of Hertwig's epithelial root sheath is unusual and may be associated with the lack of resorption of the primary teeth. Dentists should be aware of this feature of hyper-IgE syndrome because timely intervention will allow normal eruption to occur.

Natural history and prevention of radiation injury.

Radiation therapy for cancers of the head and neck can irreversibly damage the salivary glands. Xerostomia (subjective oral dryness) develops within the first week of therapy and is progressive, with devastating effects on the quality of life of the individual. The xerostomia does not correlate with the degree of salivary gland hypofunction. The mechanism of tissue injury in humans is still unclear, but much progress has been made with animal models. This paper reviews the natural history of radiation damage to human salivary glands and highlights the inter-individual variations in the responses to and recovery from therapeutic radiation. The degree of salivary gland damage is correlated to the dose of radiation delivered and the volume of gland included in the field of radiation. The molecular mechanism of acute radiation damage is not fully understood; however, long-term salivary gland dysfunction is associated with both loss of gland weight and loss of acinar cells. Various strategies have been used to prevent or alleviate the problem of salivary gland hypofunction following therapeutic radiation. This paper reviews the progress made to date and the possibilities for future interventions to prevent radiation damage.

Safety and efficacy of adenovirus-mediated transfer of the human aquaporin-1 cDNA to irradiated parotid glands of non-human primates.

This study evaluated the safety and efficacy of a single administration of a recombinant adenovirus encoding human aquaporin-1 (AdhAQP1) to the parotid glands of adult rhesus monkeys. In anticipation of possible clinical use of this virus to correct irradiation damage to salivary glands, AdhAQP1 was administered (at either 2 x 10(9) or 1 x 10(8) plaque-forming units/gland) intraductally to irradiated glands and to their contralateral nonirradiated glands. Radiation (single dose, 10 Gy) significantly reduced salivary flow in exposed glands. Virus administration resulted in gene transfer to irradiated and nonirradiated glands and was without untoward local (salivary) or systemic (sera chemistry, complete blood count) effects in all animals. However, the effect of AdhAQP1 administration varied and did not result in a consistent positive effect on salivary flow rates for all animals under these experimental conditions. We conclude that a single adenoviral-mediated gene transfer to primate salivary glands is well-tolerated, although its functional utility in enhancing fluid secretion from irradiated parotid glands is inconsistent.

Primary failure of tooth eruption: a unique case.

Primary failure of tooth eruption rarely occurs. This case represents a rare clinical situation and appears to reflect a generalized disturbance in the eruptive process, inasmuch as (1) deciduous and permanent dentition are affected, (2) incisors, molars, and premolars are involved in all quadrants, (3) skeletal and craniofacial growth are within normal limits, and (4) no systemic/genetic anomalies were detected. This is the first such case reported in the literature; diagnosis and management are discussed.

Management of gingival overgrowth associated with generalized enamel defects in a child.

Gingival overgrowth is usually associated with systemic conditions or treatment (e.g. blood dyscrasias, anti-epileptic or immunosuppressive agents). A child is presented, who had enlarged gingiva associated with a generalized enamel defect (amelogenesis imperfecta (AI), hypoplastic type) and document the periodontal and restorative management of this case.

Evaluation of oral problems in an osteogenesis imperfecta population.

OBJECTIVE: The incidence of craniofacial and dental anomalies in children with the more severe nonlethal forms of osteogenesis imperfecta was evaluated. STUDY DESIGN: The study evaluated 40 children (age range, 1-17.5 years) with types III and IV osteogenesis imperfecta. In each case, the dentition was evaluated for the presence of dentinogenesis imperfecta, attrition, and caries, as well as for radiographic appearance, dental development, and malocclusion. RESULTS: The incidence of dentinogenesis imperfecta was greater than 80% in the primary dentition. Clinically, the color of the dentition was of predictive value in appropriate management of the primary dentition. Tooth discoloration and attrition did not occur to the same extent in the permanent dentition as in the primary dentition in either group. Class III dental malocclusion occurred in 70% to 80% of this osteogenesis imperfecta population, with a high incidence of anterior and posterior cross bites and open bites. A delay in dental development was observed in 21% of patients type III osteogenesis imperfecta, whereas accelerated development was noted in 23% of the patients with type IV. In addition, ectopic eruption occurred in 13 patients. CONCLUSIONS: In addition to dentinogenesis imperfecta, significant oral problems occur in types III and IV osteogenesis imperfecta. Other features that impact the dental management of this population are highlighted.

Hyper-IgE syndrome with recurrent infections--an autosomal dominant multisystem disorder.

BACKGROUND: The hyper-IgE syndrome with recurrent infections is a rare immunodeficiency characterized by recurrent skin and pulmonary abscesses and extremely elevated levels of IgE in serum. Associated facial and skeletal features have been recognized, but their frequency is unknown, and the genetic basis of the hyper-IgE syndrome is poorly understood. METHODS: We studied 30 patients with the hyper-IgE syndrome and 70 of their relatives. We took histories, reviewed records, performed physical and dental examinations, took anthropometric measurements, and conducted laboratory studies. RESULTS: Nonimmunologic features of the hyper-IgE syndrome were present in all patients older than eight years. Seventy-two percent had the previously unrecognized feature of failure or delay of shedding of the primary teeth owing to lack of root resorption. Common findings among patients were recurrent fractures (in 57 percent of patients), hyperextensible joints (in 68 percent), and scoliosis (in 76 percent of patients 16 years of age or older). The classic triad of abscesses, pneumonia, and an elevated IgE level was identified in 77 percent of all patients and in 85 percent of those older than eight. In 6 of 23 adults (26 percent), IgE levels declined over time and came closer to or fell within the normal range. Autosomal dominant transmission of the hyper-IgE syndrome was found, but with variable expressivity. Of the 27 relatives at risk for inheriting the hyper-IgE syndrome, 10 were fully affected, 11 were unaffected, and 6 had combinations of mild immunologic, dental, and skeletal features of the hyper-IgE syndrome. CONCLUSIONS: The hyper-IgE syndrome is a multisystem disorder that affects the dentition, the skeleton, connective tissue, and the immune system. It is inherited as a single-locus autosomal dominant trait with variable expressivity.

Radiation-induced progressive decrease in fluid secretion in rat submandibular glands is related to decreased acinar volume and not impaired calcium signaling.

The mechanism(s) of radiation-induced salivary gland dysfunction is poorly understood. In the present study, we have assessed the secretory function (muscarinic agonist-stimulated saliva flow, intracellular calcium mobilization, Na+/K+/2Cl- cotransport activity) in rat submandibular glands 12 months postirradiation (single dose, 10 Gy). The morphological status of glands from control and irradiated rats was also determined. Pilocarpine-stimulated salivary flow was decreased by 67% at 12 months (but not at 3 months) after irradiation. This was associated with a 47% decrease in the wet weight of the irradiated glands. Histological and morphometric analysis demonstrated that acinar cells were smaller and occupied relatively less volume and convoluted granular tubules were smaller but occupied the same relative volume, while intercalated and striated ducts maintained their size but occupied a greater relative volume in submandibular glands from irradiated compared to control animals. In addition, no inflammation or fibrosis was observed in the irradiated tissues. Carbachol- or thapsigargin-stimulated mobilization of Ca2+ was similar in dispersed submandibular gland cells from control and irradiated animals. Further, [Ca2+]i imaging of individual ducts and acini from control and irradiated groups showed, for the first time, that mobilization of Ca2+ in either cell type was not altered by the radiation treatment. The carbachol-stimulated, bumetanide-sensitive component of the Na+/K+/ 2Cl- cotransport activity was also similar in submandibular gland cells from control and irradiated animals. These data demonstrate that a single dose of gamma radiation induces a progressive loss of submandibular gland tissue and function. This loss of salivary flow is not due to chronic inflammation or fibrosis of the gland or an alteration in the neurotransmitter signaling mechanism in the acinar or ductal cells. The radiation-induced decrease in fluid secretion appears to be related to a change in either the water-handling capacity of the acini or the number of acinar cells in the gland.

The mouth is a gateway to the body: gene therapy in 21st-century dental practice.

Gene therapy may become an integral tool in dental practice early in the 21st century. It and other biological therapies are expected to be applied to oral diseases and disorders during the midpractice lifetime of today's dental students. If the applications of oral gene transfer are expanded to systemic diseases, oral health care providers in the future could routinely be "gene therapists" with therapeutic targets well outside the oral cavity.