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The frequency of first permanent molar treatment for children with MIH is nearly 10 times greater compared to children without MIH. The available treatment modalities for MIH is extensive but the decision on which treatment should be used is complex and multi-factorial. Factors may include: condition severity, the patient’s dental age, the child/parent’s social background and expectations. There are treatment modalities available to manage children affected by MIH; however, the evidence supporting these modalities are still weak.
Involves repeated cycles of etching with 37% phosphoric acid followed by applying 5% sodium hypochlorite until improvement of discolouration is achieved. Clear resin composite or resin infiltrate can be used to seal the lesion after the technique.
If cause-specific measures are insufficient, soft-tissue graft surgery may be used to create more gingiva. The tissue used may be autologous tissue from another site in the patient's mouth, or it can be freeze-dried tissue products or synthetic membranes. New research is focused on using stem cells to culture the patients' own gums to replace receded gums.
All impacted teeth, unless otherwise contraindicated, are considered for surgical removal. Thus, dental extractions will often take place. The type of extraction (simple or surgical) often depends on the location of the teeth.
In some cases, for aesthetic purposes, a surgeon may wish to expose the canine. This may be achieved through open or closed exposure. Studies show no advantage of one method over another.
Cosmetic or functional intervention may be required if tooth surface loss is pathological or if there has been advanced loss of tooth structure. The first stage of treatment involves managing any associated conditions, such as fractured teeth or sharp cusps or incisal edges. These can be resolved by restoring and polishing sharp cusps. Then, desensitizing agents such as topical fluoride varnishes can be applied, and at home desensitising toothpastes recommended. Many restorative options have been proposed, such as direct composite restorations, bonded cast metal restorations, removable partial dentures, orthodontic treatment, crown lengthening procedures and protective splints. The decision to restore the dentition depends on the wants and needs of the patient, the severity of tooth surface loss and whether tooth surface loss is active. The use of adhesive materials to replace lost tooth structure can be performed as a conservative and cost-effective approach before a more permanent solution of crowns or veneers is considered.
Where there is an operculum of gingiva overlying the tooth that has become infected it can be treated with local cleaning, an antiseptic rinse of the area and antibiotics if severe. Definitive treatment can be excision of the tissue, however, recurrence of these infections is high. Pericoronitis, while a small area of tissue, should be viewed with caution, because it lies near the anatomic planes of the neck and can progress to life-threatening neck infections.
The treatment aims are to eliminate the bacteria from the exposed surface of the root(s) and to establish the anatomy of the tooth, so that better plaque control can be achieved. Treatment plans for patients differ depending on the local and anatomical factors.
For Grade I furcation, scaling and polishing, root surface debridement or furcationplasty could be done if suitable.
For Grade II furcation, furcationplasty, open debridement, tunnel preparation, root resection, extraction, guided tissue regeneration (GTR) or enamel matrix derivative could be considered.
As for Grade III furcation, open debridement, tunnel preparation, root resection, GTR or tooth extraction could be performed if appropriate.
Tooth extraction is usually considered if there is extensive loss of attachment or if other treatments will not obtain good result (i.e. achieving a nice gingival contour to allow good plaque control).
Depending on the shape of the gum recession and the levels of bone around the teeth, areas of gum recession can be regenerated with new gum tissue using a variety of gum grafting "periodontal plastic surgery" procedures performed by a specialist in periodontics (a periodontist). These procedures are typically completed under local anesthesia with or without conscious sedation, as the patient prefers. This may involve repositioning of adjacent gum tissue to cover the recession (called a pedicle graft) or use of a free graft of gingival or connective tissue from the roof of the mouth (called a "free gingival graft" or a Subepithelial connective tissue graft). Alternatively, a material called acellular dermal matrix (processed donated human skin allograft) may be used instead of tissue from the patient's own palate.
Treatment for TRs is limited to tooth extraction because the lesion is progressive. Amputation of the tooth crown without root removal has also been advocated in cases demonstrated on a radiograph to be type 2 resorption without associated periodontal or endodontic disease because the roots are being replaced by bone. However, X-rays are recommended prior to this treatment to document root resorption and lack of the periodontal ligament.
Tooth restoration is not recommended because resorption of the tooth will continue underneath the restoration. Use of alendronate has been studied to prevent TRs and decrease progression of existing lesions.
Preventive maintenance therapy for the oral effects of TDO involve frequent dental cleanings, professional application of desensitizing medication, diet counseling, and oral hygiene instructions in proper home care and maintenance; medicated dental rinses and toothpastes are also prescribed as people suffering from TDO are more prone to oral hard tissue disease and early tooth loss. If restorative dentistry is performed without orthodontics to correct the protrusion of the lower jaw, a dental night guard worn at bedtimes on the upper or lower teeth to protect them from the effects of grinding may be recommended.
In extreme cases, tooth loss is inevitable, and the patient will consult with a prosthodontist to determine tooth replacement options such as dental implants, or partial dentures. There is no cure for TDO, but managing its oral and systemic affects is key to having the most favorable outcome from the disease. As the person affected by TDO ages, increased bone fractures may occur. The person suffering from TDO should watch for any pimple like masses on the gum tissue, pain or soreness in the teeth and gums, broken or chipped teeth, feeling of water in the ear or severe pain in the extremities which could indicate fracture.
Treatment is only required if the occlusion or bite of the person is compromised and causing other dental problems. Multiple long-term clinical problems can arise such as occlusal interferences, aesthetic disturbances, loss of pulp vitality, irritation of tongue during mastication and speech, caries and displacement of the affected tooth. Most people with talon cusp will live their normal lives unless the case is severe and causes a cascade of other dental issues that lead to additional health problems. This dental anomaly would not be considered fatal. Generally talon cusps on lower teeth require no treatment, but talon cusps on upper teeth may interfere with the bite mechanics and may need to be removed or reduced.
Small talon cusps that produce no symptoms or complication for a person can remain untreated. However large talon cusps should not.
Some common treatments include:
- Fissure sealing
- Composite resin restoration
- Reduction of cusp
- Pulpotomy
- Root canal (endodontic treatment)
- Extraction
The condition is usually benign, but it can cause mild irritation to soft tissues around the teeth and the tongue, and if large enough, may pose an aesthetic problem. Talon cusps that are too large are filed down with a motorized file, and then endodontic therapy is administered.
In order to prevent any future dental complications, when talon cusp is present due to an early diagnosis it would be best to see a dentist regularly every six months for routine dental checkups, remain under observation, brush and floss properly and undergo regular topical applications of fluoride gel to prevent caries and to promote enamel strength.
If the aetiology of abrasion is due to habitual behaviours, the discontinuation and change of habit is critical in the prevention of further tooth loss. The correct brushing technique is pivotal and involves a gentle scrub technique with small horizontal movements with an extra-soft/soft bristle brush. Excessive lateral force can be corrected by holding the toothbrush in a pen grasp or by using the non-dominant hand to brush. If abrasion is the result of an ill-fitting dental appliance, this should be corrected or replaced by a dental practitioner and should not be attempted in a home setting.
Unerupted microdonts may require surgical removal to prevent the formation of cysts. Erupted microdonts, peg laterals especially, may cause cosmetic concern. Such teeth may be restored to resemble normal sized teeth, typically with composite build ups or crowns. Orthodontics may be required in severe cases to close gaps between the teeth.
When a diagnosis of bruxism has been confirmed, it is recommended that the patient buy a full-coverage acrylic occlusal splint, such as a Michigan Splint or Tanner appliance, to prevent further bruxism. Patients must be monitored closely, with clinical photographs 6–12 monthly to evaluate if the tooth surface loss is being prevented.
In order for successful treatment of abrasion to occur, the aetiology first needs to be identified. The most accurate way of doing so is completing a thorough medical, dental, social and diet history. All aspects needs to be investigated as in many cases the cause of abrasion can be multi-factorial. Once a definitive diagnosis is completed the appropriate treatment can commence.
Treatment for abrasion can present in varying difficulties depending on the current degree or progress caused by the abrasion. Abrasion often presents in conjunction with other dental conditions such as attrition, decay and erosion however the below treatment is for abrasion alone. Successful treatment focuses on the prevention and progression on the condition and modifies the current habit/s instigating the condition.
The hair, teeth, and skeletal side effects of TDO are lifelong, and treatment is used to manage those effects. A person with TDO has the same life expectancy as a person without TDO. There are no cures or medications used to treat systemic effects of TDO, but medications for the frequent ear and dental infections can be used to manage its symptoms. A team based approach between dental specialists, oral and maxillofacial surgeons, and physicians is necessary for treating the systemic effects and improves the prognosis. It is also recommended for affected individuals to seek counseling to be better able to cope with any psychosocial problems due to oral and facial abnormalities that occur with TDO.
At home, a person suffering from TDO may be instructed to use frequent deep conditioning treatments and low manipulation hair styling to control shedding and hair loss. Clinical treatment involves the use of radiology to determine the effects that TDO has had on the surrounding teeth and bone structures. A series of appointments with the healthcare team are usually necessary to correct TDO abnormalities with treatment duration lasting from several months to through full oral-facial maturation stages.
Endodontic procedures are routinely recommended due to treatdental pulp exposure or periodontal abscess. Maxillofacial surgery may be required to establish a more appropriate mastication, skeletal, and esthetic relationship vertically between the teeth to improve functioning. Esthetic procedures such as dental crown (dentistry) or veneer (dentistry) are often performed to improve the physical look of the teeth and to strengthen the weak enamel caused by TDO.
No intervention is usually recommended unless they are causing difficulty to the infant or mother.
However some recommend that they be removed as the tooth can cut or amputate the tip of the tongue.
They should be left in the mouth as long as possible to decrease the likelihood of removing permanent tooth buds with the natal tooth. They should also not be removed if the infant has hypoprothrombinemia. In case of complications when the natal teeth need to be removed, dental radiographs should be obtained whenever possible, and evaluated and followed up with pediatric dentists.
Wisdom teeth that are fully erupted and in normal function need no special attention and should be treated just like any other tooth. It is more challenging, however to make treatment decisions with asymptomatic, disease-free wisdom teeth, i.e. wisdom teeth that have no communication to the mouth and no evidence of clinical or radiographic disease (see Treatment controversy below).
Although these teeth are usually asymptomatic and pose no threat to the individual, they are often extracted for aesthetic reasons. This is done particularly if the mesiodens is positioned in the maxillary central incisor region. The traditional method of removal is done by using bone chisels, although a more advanced technique has been found to be more beneficial, especially if surgery is required . Through the use of Piezoelectricity, Piezoelectric ultrasonic bone surgery may be more time consuming than the traditional method but it seems to reduce the post-operative bleeding and associated complications quite significantly.
Treatment options include antibiotic therapy (not a permanent solution), endodontic (root canal) therapy, or extraction.
Before root canal treatment or extraction are carried out, the clinician should have thorough knowledge about the root canal morphology to avoid complications.
Dental fluorosis may or may not be of cosmetic concern. In some cases, there may be varying degrees of negative psychosocial effects. The treatment options are:
- Tooth bleaching
- Micro-abrasion
- Composite fillings
- Veneers
- Crowns
Generally, more conservative options such as bleaching are sufficient for mild cases.
The current standard of care for Severe Early childhood caries includes restoration and extraction of carious teeth and, where possible, includes early intervention which includes application of topical fluoride, oral hygiene instructions and education.
The initial visit is important as it allows dental professionals to flag unfavourable behaviour or eating habits. This will also allow dental clinician, working in a collaborative team, to perform diagnostic testing to determine the rate and progression of the disease. This is done by performing risk assessment based on the child's age, as well as the social, behavioural, and medical history of the child. Children at low risk may not need any restorative therapy, and frequent visits should be made to detect possible early lesions. Children at moderate risk may require restoration of progressing and cavitated lesions, while white spot and enamel proximal lesions should be treated by preventive techniques and monitored for progression. Children at high risk, however, may require earlier restorative intervention of enamel proximal lesions, as well as intervention of progressing and cavitated lesions to minimize continual caries development.
As Early Childhood Caries occurs in children under the age of 5, restorative treatment is generally performed under general anaesthetic to ensure optimal results and prevent a traumatic experience for the child.
Depending on the level of cavitation of the teeth, different types of restorations may be employed. Stainless steel (preformed) crowns are pre-fabricated crown forms which can be adapted to individual primary molars and cemented in place to provide a definitive restoration.They have been indicated for the restoration of primary and permanent teeth with caries where a normal filling may not last.
Another approach of treating dental caries in young children is Atraumatic Restorative Treatment (ART). The ART is a procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. This is useful to prevent trauma and requires less chair time for the young patients. This is used in cases where the teeth are being maintained in the mouth to maintain space for the future teeth to come through.
Treatment is usually symptomatic, (i.e., analgesic medications) and also the removal of debris from the socket by irrigation with saline or local anesthetic. Medicated dressings are also commonly placed in the socket; although these will act as a foreign body and prolong healing, they are usually needed due to the severe pain. Hence, the dressings are usually stopped once the pain is lessened. Examples of medicated dressings include antibacterials, topical anesthetics and obtundants, or combinations of all three, e.g., zinc oxide and eugenol impregnated cotton pellets, alvogyl (eugenol, iodoform and butamen), dentalone, bismuth subnitrate and iodoform paste (BIPP) on ribbon gauze and metronidazole and lidocaine ointment. A systematic review of the efficacy of treatments for dry socket concluded that there was not enough evidence to discern the effectiveness of any treatments. People who develop a dry socket typically seek medical/dental advice several times after the dental extraction, where the old dressing is removed, the socket irrigated and a new dressing placed. Curettage of the socket increases the pain and has been discouraged by some.
The management depends on the type of injury involved and whether it is a baby or an adult tooth. The Dental Trauma Guide is an evidence-based and up-to-date resource to aid management of dental trauma. If teeth are completely knocked out baby front teeth should not be replaced. The area should be cleaned gently and the child brought to see a dentist. Adult front teeth (which usually erupt at around 6 years of age) can be replaced immediately if clean. See below and the Dental Trauma Guide website for more details. If a tooth is avulsed, make sure it is a permanent tooth (primary teeth should not be replanted, and instead the injury site should be cleaned to allow the adult tooth to begin to erupt).
- Reassure the patient and keep them calm.
- If the tooth can be found, pick it up by the crown (the white part). Avoid touching the root part.
- If the tooth is dirty, wash it briefly (10 seconds) under cold running water but do not scrub the tooth.
- Place the tooth back in the socket where it was lost from, taking care to place it the correct way (matching the other tooth)
- Encourage the patient to bite on a handkerchief to hold the tooth in position.
- If it is not possible to replace the tooth immediately, place it in a glass of milk or a container with the patient's saliva or in the patient's cheek (keeping it between the teeth and the inside of the cheek - note this is not suitable for young children who may swallow the tooth). Transporting the tooth in water is not recommended, as this will damage the delicate cells that make up the tooth's interior.
- Seek emergency dental treatment immediately.
The poster "Save a Tooth" is written for the public and is available in several languages—Spanish, English, Portuguese, French, Icelandic, Italian—and can be obtained at the IADT website.
For other injuries, it is important to keep the area clean - by using a soft toothbrush and antiseptic mouthwash such as chlorhexidine gluconate. Soft foods and avoidance of contact sports it also recommended in the short term. Dental care should be sought as quickly as possible.