Q&A
Here are the questions, answers and comments regarding the lectures of Copenhagen Webinars 2023
Prof. Zafer Cehreli
Webinar: Revascularization from a clinical perspective: The present and foreseeable future
Q: Thanks for the great lecture. I just want to clarify when you said not to provoke bleeding in the canal to avoid uncontrolled obliteration of the canal but at the same time you placed pulpal tissue from primary tooth with the blood that was coming through, isn’t it?
A: Both excellent questions! Many thanks for watching!
Yes, that is not evoked bleeding from the apex of the recipient permanent tooth to be revascularized, but instead, the bleeding from extirpation in the primary donor tooth.
Q: Also, you only recommend the use of Sodium hypochlorite without EDTA? is it?
A: Yes. EDTA helps cell differentiation in favor of biomineralization.
Webinar: Minimally-invasive esthetic treatment of demineralized and hypomineralized teeth
Q: In the videos, grooves are cut in to the cured composite when building up the dentine and enamel shades in order to copy the appearance of adjacent teeth. Will the new composite bond to the composite that has just been cut?
A: Yes, provided that you use universal bonding agents.
Q: I thought composite bonded to freshly cured composite due to inhibition of the surface layer?
A: Correct, that is what happens when you place composite increments on one another.
Q: However, if you cut in to it I would have thought it may not bond properly?
A: Until universal adhesives, this was a problem, and additional measures such as sandblasting, and etching did not help.
Q: Does any preparation need to be done to the cut composite, such as sandblasting, etching and or bonding and is the bond between the cured composite and newly applied composite affected/compromised in any way?
A: No. Some authors etch the surface with 37% Phosphoric acid for 5 seconds to remove the composite smear as an optional step, but this has other been verified with any study.
Webinar: Treatment challenges with composite resins
Q: Thanks for the excellent lecture. I would like to clarify about Sodium hypochlorite- you said you used it to bleach the brown discoluration off- is it the same as milton that we use for canal irrigation?
A: Yes, freshly-prepared 5-5.25% Sodium hypochlorite.
Q: And then did you etch with normal etching to get rid of oxygen? is that right?
A: No, we use the Icon etch instead.
Dr. Kate Kenny
Q: Dear Dr Kenny,
Thank you so much for your presentation. I run a small trauma clinic in a DGH in Surrey, we are a small paediatric dentistry department, but due to access to services in our region we see quite a lot of dental trauma. We have been thinking for some time about collecting data on patient reported outcomes, both from management of initial trauma in primary care and as feedback on our own service (we don’t have a walk in service so almost all of our trauma is referred from primary care).
Which QOL questionnaire did you use for children in your research, and which objective assessment of pain did you use?
All the best for your thesis, I think this is really important research.
A:
Pain
We measure frequency and intensity of pain.
Intensity
Children under 10 years – Wong Baker Faces pain scale
Children over 10 years, and adults – Visual analogue scale
Frequency
Children under 10 – Thinking about pain from your injured tooth. How often does your tooth bother you? Not at all/ a bit/ a lot
Children over 10 – How often does your tooth bother you? Never/ once or twice/sometimes/often/everyday/don’t know
Measuring pain in this way has proven quite straightforward – in our just finished feasibility test it was record in over 90% of patients. Clinicians found it a useful prompt to start discussion with children and families about pain.
Quality of Life
We are currently using the ‘global’ questions from the Core Outcome Set for TDI. This has proved more challenging as the questions differ (albeit very slightly) depending on age. Clinicians have expressed concern that the language used in the questions is not that accessible. So I think this is an area that will require more work in the future
7-14 years old
Parents, thinking about the impact of the injured tooth or teeth have had,
How much is your child’s overall well being affected by the condition of their teeth? Not at all/ very little/some/a lot/very much
How much is the daily life of your family affected by the condition of their teeth? Not at all/ very little/ some/ a lot/ very much
15-16 years old
How would you rate the health of your teeth? Very good/good/OK/poor
How much do your teeth or mouth bother you? Not at all/ a little bit/some/a lot
Dr. Josephine Solgaard
Q: Please could you confirm the conclusion of this session? Are you advocating RCT of mature teeth with lateral luxation within 2 weeks?
A: We found a potential for pulp revascularization for patients below the age 25. BUT it is important to say, that we recommend that you always follow the international guidelines for management of traumatic dental injuries. This means that you need to perform prophylactic RCT of mature teeth with lateral luxation within 2 weeks after the injury.
Q: How a pulp aximeter modified for pulp testing?
A: I do not understand the question
Q: When the tooth is discoloured and patient/parents demands whitining and we advice them not to and wait and see, but later they ended up with complications such as resoption or abscess formation – they might sue us for negligence! isn’t it? how can we balance
A: You need to follow and advise your patients to follow the international guidelines for management of traumatic dental injuries.
Q: How often do you do your follow-ups in lateral luxation in these cases? Every 2 weeks for the first 3-6 months? Thank you in advance!
A: I follow the international guidelines which means follow up visits:
Clinical and radiographic follow-up after 2 weeks.
Clinical and radiographic follow-up and splint removal after 4 weeks.
Clinical and radiographic follow-up after 8 weeks, 12 weeks, 6 months, 1 year and yearly for 5 years.
Prof. Dr. Liran Levin
Q: In the videos it seems a high speed turbine is used with water to attempt to clean the implants suffering from peri-implantitis. Is there not a high risk of surgical emphysema when doing this?
A: Great question. Indeed a physio-dispenser would be preferred.
Dr. Eva Lauridsen
Q: Thank you Dr Eva, The topic of delayed re-implantation is very important for hospital dentistry. We had a lot of patients after sever trauma which indicated intensive medical care from 2 weeks to a month. later, as patient case stabilized, avulsion noticed. In these cases, delayed implantation is the only options. Dealing with healing socket (granulation tissue) should be removed and replantation should be done. I suggest the addition of this topic to the guideline to avoid confusion and prevent guiding the dentist to do nothing as some dentists follow the guideline as a holy book from GOD.
A: That’s is a very good point. We cannot change the guidelines before the IADT guidelines are opdated next time but I absolutely agree with you that this should be included in the future.
Best Regards, Eva Lauridsen
Prof. Lars Andersson
Q: As usual great lecture Dr Lars, I would like to highlight the importance of considering child cooperativity as factors that make de-coronation an acceptable management option for us as pediatric dentist compared to risk of multiple distraction (surgical luxation). I agree with you that distraction should be done early but carry a risks.
I would like to ask; how much tooth infra-occlusion position (in mm) is considered a must for de-coronation? especially in growing children!! Some prefer to delay de-coronation till complete loss of root regardless the infra-position depth, while others prefer to de-coronate early and kept child with prosthetic replacement consequences till later age for implant ” which we don’t prefer as pediatric dentist based on patient frequent complains with prosthesis.”
A: I think this is depending on where the child is in his/her growth. If the child is early in his/her growth we expect a lot of infraocclusion, and a good time to do decoronation is when the infraocclusion is 1-1.5mm, while in children who have passed the pubertal growth spurt there is not so much infraposition to be expected so a more expectance approach can be taken
Q: Thank you so much for the comprehensive lecture.
In a growing child when we suspect replacement resorption- does it matter if we complete root filling with GP or should we just keep it empty (after 2 weeks of Ca(OH)2 and seal the access cavity?
A: I would prefer to using Calcium hydroxide
Q: Hello prof. Andersson, very nice presentation. I have a question, what happened to Dr Andreasen to his teeth to be so much motivated to investigate dental trauma? Did he had avulsion? and what happened after? he had implants or what treatment he had? Thank you
A: He told me he had a crown fracture with a discoloration of the crown, that no none knew how to treat because this was in the 1940s and we had very little knowledge on discoloration at that time. Later in his life, the tooth was root canal treated and treatment of the discoloration was carried out.
Q: Thank you for a good presentation! I have som questions.
Can you do decoronation on a vital tooth or do you have to remove the pulp first?
A: It is better to remove the pulp before decoronation.
Q: What if the tooth is obliterated?
A: When decoronating the tooth as much dentin as possible centrally shall be removed by using a round bur.
Q: If it´s possible to decoronate a vital tooth , how do I handle the pulp tissue? Should I use biodentine?
A: Remove the pulp, Calcium hydroxide may be the best alternative
Q: If you have passed the pubertal growth spurt and you´re not supposed to grow any more and you have an incisor that is already in infraposition, should I do decoronation or is it better to leave the tooth in place,, since decoronation will not benefit bone apposition? Or is it valuable/positive for the maxilla and surrounding teeth?
A: The effect of infraposition in such a case, who have passed the pubertal growth spurt, is very limited on the infraposition. So just let the tooth stay until it is completely resorbed.
Dr. Nestor Tzimpoulas
Q:
What type of collagen sponge are you using in the case with the root crown fracture?
Thank you!
A: Collacote
Q: Dear Nestor
Many thanks for your presentation on VPT. I note you used a round tungsten carbide bur for pulp removal. Any particular brand? I assume you use tungsten carbide instead of diamond as it less destructive?
A: Thank you very much. Yes I use a tungsten carbide bur on a high-speed airotor under water because the pulp amputation is smoother than doing with slow speed carbide where the pulp can be easier pulled or locked in the flutes of the bur. I use the Meisinger carbide burs from Germany of size 10 or 12
Q:
Thank you for the wonderful presentation. Would the results be the same if there was no rubber cover (cofferdam) around the tooth like many dentist do ( if they are not in a specialistclinic).
Thank you
A: Thank you very much. I think that one of the most important prerequisites in such treatments is the placement of a rubber dam. It is not only the saliva that contain bacteria but also in the humidity and breathing from the patient may also contain bacteria. There is no such study as far as I know evaluating with or without rubber dam the success rates in such treatments, however it is highly recommended to place it if possible. It takes usually 30 sec of time.
Q: Thanks for enlightn us with practical tips
what do you mean with dual cure composite? is it compomer?
A: Thank you very much. Dual cure resin modified composite build up that has a chemical binding reaction to dentin and sets also under polymerization light.
Q: Thank you for the great presentation. In the case for the full pulpotomy where collagen sponge was placed over the pulp, what was the purpose of the collagen sponge? Does biodentine need to be in contact with the pulp in order to promote pulpal healing? And would the collagen sponge resorb to leave a gap between the biodentine and pulp? Thank you!
A: Thank you very much, the purpose of the collagen sponge was to assist in creating a barrier on the pulp surface because it was difficult to achieve hemostasis in such large surface and to reduce chair time. As long as the collagen soaks blood from the pulp it creates a spongy like consistency on which you can apply the biomaterial easier and adapt it. The collagen within then next 1-2 weeks will be slowly resolved and the pulp will come into contact with the biomaterial to promotes tertiary dentin as it was shown in that case after one year of follow up, so no gap is left since the cells from the pulp will proliferate to reach the surface of the biomaterial.
Prof. Hani Nazzall
Q: Great lecture Dr Hani, The best summary. God bless you. I am sorry that you could not share the common questions in your presentation.
A: Thank you for your feedback. I am pleased to know that you liked the presentation and found it beneficial. Apologies as the slides are not self explanatory so you won’t benefit.
Q: If you decide to perform REP, what does the clinician do if a blood clot does not fill the canal? Do you go to plan B and apical plug?
A: If no blood at all then yes. If minimal blood is evident, then it’s your decision. There is no
evidence at this stage to correlate amount of bleeding with success.
Q: Have you forewarned the patient and guardian of this possibility?
A: Certainly, this is part of your informed consent process.
Q: How often is there no blood clot?
A: It can happen. This is multifactorial therefore I do not know of a percentage.
Q: Dear Prof Hani
Many thanks for your excellent presentation. What sort of instrument do you use to create the blood clot. A hand file? Of any particular size?
A: A hand file, no particular size, a 25 file should be ok
Q: With respect to collagen plugs – are these easy to obtain?
A: Depends on the region you are in and suppliers. Your Endo colleagues should be able to help you.
Q: In case of this treatment method failing – would you then carry out MTA plug?
A: Yes.
Q: Thank you for great lecture!
If pulp vitality is an outcome when are we expected to perform sensibility test?
A: Unfortunately with the three layers of obturation material I doubt we could get a reliable response
Q: Thank you for the lecture. I am very interested in RET as I treat many children post-trauma in London. However, I have not across anyone in London or the UK currently using this technique> Please advise whom I could approach for further guidance, before embarking on this treatment method.
A: I am not sure who performs this technique in London. I used to do it all the time while in leeds but since moved to Qatar. Might be worth contacting the paediatric or Endo team at one of London’s dental institutes.
Dr. Helén Isaksson
Q: Thanks for the nice lecture. I would like to clarify when to initiate pulp therapy in the coronal part if there was extrusion or lateral laxation and later the tooth is discoloured? should we wait for pain and abscess formation?
A: Thanks´ for your question.
With referral to this study, Malmgren B, Hübel S. Transient discoloration of the coronal fragment in intra-alveolar root fractures. Dent Trauma 2012;28:200-204, it is important to consider that a discoloration and/or loss of sensibility per se, does not indicate pulp necrosis. Transient discoloration in intra-alveolar fractures is relatively common and it indicates a good prognosis for healing. Other signs and symptoms, such as pulp calcification and bony radiographic changes must be taken into consideration as well. The study showed that discoloration disappeared within 4 weeks to 6 months. Sensibility was regained successively as the discoloration disappeared.
But we also know that with dislocation of the coronal fragment and increasing distance between fragments/diastasis, the chance of pulp necrosis is increased and healing progressively worsened with increased mm diastase between fragments. (Andreasen JO, Andreasen FM, Mejáre I, Cvek M. Healing of 400 intra-alveolar root fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dent Traumatol 2004;20:192-202.)
With this in mind, I hope this will facilitate your care and further treatment plans.
Best regards Helén Isaksson
Dr. Georgios Tsilingaridis
Q: Since the risk of resorption is high in intrusion- what material should we fill the canal with after pulp extirpation and placement of Ca(OH)2 for 2 weeks? should we keep it empty? avoid the use of MTA plug? and only ensure good seal?
A: If you have diagnosed pulp necrosis after an intrusion in a growing young patient you should start RCT, fill it with calcium hydroxide and leave it for 6 months and do follow up. After 6 months change the dressing and wait another 6 months. After one year, there is no signs of replacement resorption, then you can do a permanent root filling with gutta-percha, since the risk for replacement resorption after 1 year is much lesser.
If it is an young adult-adult you can do the permanent root filling within 4-6 weeks since the replacement resorption process is very slow compared to in a young growing individual.
Best regards Dr. Tsilingaridis