Dental Update

Obstructive sleep apnoea (OSA) is episodic total or partial airway collapse, causing interrupted sleep, excessive snoring and tiredness. Patients at risk of OSA may be identified by their general dental practitioner (GDP), and referred to a medical professional for diagnosis and treatment. Management includes advice on lifestyle and sleep hygiene; continuous positive airway pressure (CPAP) is the most effective treatment for OSA. Patients with mild-moderate OSA or are unable to tolerate or benefit from CPAP therapy may be provided with a mandibular advancement splint (MAS), which is prescribed by an orthodontist or other trained dental professional. The GDP has a role in ensuring patients are dentally fit for MAS treatment and in monitoring them. CPD/Clinical Relevance: The symptoms, causes and treatment for obstructive sleep apnoea are useful to know.

Single tooth loss in the aesthetic zone owing to trauma is a challenging yet common clinical situation. Loss of adequate bony support, additional requirements for bone grafts or unwillingness to undergo dental implant treatments means treatment options are restricted to the conventional, fixed dental prosthesis with the adjacent teeth used as abutments. An extended pontic area owing to a pre-existing midline diastema contradicts the use of a conventional, minimally invasive resin-bonded fixed dental prosthesis that bonds to the palatal surface of abutment teeth. This technique highlights a novel reverse anterior Maryland bonded (RAMBo) bridge concept that prepares the labial surface of abutment teeth only, with the fabrication of a three-unit, all-ceramic, partial coverage dental prosthesis used in the replacement of a single missing anterior tooth. The RAMBo treatment described here uses adhesive bonding with contemporary veneers and a pontic to replace a missing tooth in an anterior aesthetic zone. CPD/Clinical Relevance: The RAMBo technique offers a minimally invasive and aesthetically favourable solution for single anterior tooth replacement in cases with extended pontic areas.

In this case study, a 19-year-old female patient with severe dental anxiety presented for a dental trauma review subsequent to an injury to the UR1 and UL1 9 years previously. This case was managed conservatively from the outset by periodic reviews. During the reviews, both the UR1 and UL1 showed no signs of infection or inflammation, but there was evidence of pulp canal obliteration in both teeth. Radiographic assessments showed healing at the fracture sites, although the apical fragment of the UL1 appeared distally displaced, which was evident from the 11-month review onwards. In addition to the trauma management, the patient was seen in a joint hypodontia clinic for potential orthodontic treatment. After 9 years, the UR1 and UL1 remained responsive to pulp sensibility tests and were asymptomatic, with no signs of infection or inflammation. CPD/Clinical Relevance: The importance of periodic post-trauma reviews, comprehensive treatment planning, conservative management of traumatized, immature permanent teeth is highlighted.

This article includes, to the best of the authors' knowledge, the first described cases of hyperkeratosis of the oral mucosa induced by playing the bagpipes. The clinical and pathological features of two cases are presented. A discussion summarizes the health implications of bagpipe playing as well as the orofacial implications of playing other musical instruments. CPD/Clinical Relevance: White patches of the oral mucosa are common, and it is important for the clinician to take a thorough history to be able to determine the likely aetiology.

Bruxism is a repetitive masticatory muscular activity characterized by the grinding and clenching of teeth and/or thrusting of the mandible. This activity can occur during the day (awake bruxism) or at night (sleep bruxism) and patients can potentially generate mandibular forces of up to 900N. This has been known to crack or break unrestored teeth, indirect restorations and even implant fixtures. This article provides an overview of the endodontic considerations in those who experience bruxism and who have cracked teeth. CPD/Clinical Relevance: Bruxism can affect tooth structural integrity and pulp vitality, and can compromise tooth survival.

Necrotizing sialometaplasia (NS) is a rare, benign inflammatory condition of the minor salivary glands that can mimic malignancy, posing a diagnostic challenge. This case report describes a 40-year-old male smoker who presented with a painful ulcer on the palate, initially misdiagnosed as a fungal infection. Clinical examination revealed a 1-cm punched-out palatal lesion near infected upper teeth. Histological analysis of a biopsy confirmed NS, with no malignancy observed. The patient showed significant healing by the 7-week follow-up with no active treatment required. This case underscores the importance of biopsy in differentiating NS from malignancy, especially in high-risk patients. CPD/Clinical Relevance: Correct diagnosis of necrotizing sialometaplasia may be difficult but is needed to ensure appropriate management.

This review investigates osteoradionecrosis (ORN), a debilitating complication of head and neck radiotherapy. It explores its aetiology, prevention and diverse management approaches. High-dose radiotherapy (≥70 cGy) and tooth extractions in irradiated areas increase ORN risk. Diagnosis involves clinical presentation, imaging using OPT, CT and MRI, and biopsy. Management ranges from conservative measures to surgery (such as sequestrectomy and reconstruction). Understanding ORN is vital to minimize its occurrence and optimize patient outcomes through preventive measures and appropriate treatment strategies. CPD/Clinical Relevance: ORN is a significant complication of head and neck radiotherapy, requiring a multidisciplinary approach for prevention, accurate diagnosis, and effective management to optimize patient outcomes.

Prion diseases, also known as transmissible spongiform encephalopathies, are progressive, fatal neurodegenerative diseases. Prion disease and dentistry has been subject to research owing to the significance of cross-contamination with dental instruments. This article discusses the provision of dental treatment for patients with prion disease, focusing on a patient with hereditary prion disease in a special care dental department. CPD/Clinical Relevance: Patients with neurodegenerative encephalopathies, such as prion diseases, may require additional support with dental treatment.

Periodontitis is caused by an inappropriate activation of the host response to plaque biofilm. The accumulation of plaque biofilm leads to dysbiosis, that is, an imbalance in microbial community composition and function, which drives tissue destruction. Historical plaque hypotheses provide a foundational understanding of the role of plaque in the pathogenesis of periodontitis {AQ – edit OK?}. More contemporary theories emphasize how dysbiosis can trigger an exaggerated host response, leading to tissue destruction and periodontitis. As periodontitis is a biofilm-related disease, clinicians should be aware of the importance of regular mechanical disruption of plaque biofilm in managing periodontitis. CPD/Clinical Relevance Practitioners should aware of the importance of regular professional mechanical plaque removal, which is integral to the overall management of periodontal disease.

The smear layer is a thin layer of tooth tissue, bacteria and infected dentine that is intimately attached to the wall of root canals. It is created during any instrumentation of the root canal and inhibits microbe removal from dentine tubules and intimate attachment of endodontic sealer, which necessitates its removal. A variety of materials for removal of the smear layer is available: this article discusses the different types and makes general recommendations on the treatment of the smear layer and the use of chelating agents in endodontic treatment. CPD/Clinical Relevance Removal of the smear layer is necessary for thorough disinfection of the root canal system and for the predictable healing of apical periodontitis.

Achieving an optimal aesthetic outcome with implant-supported crowns in the aesthetic zone remains one of the biggest challenges in implant dentistry. A 34-year-old female patient, with no significant systemic pathology, came to the dental office to receive treatment for an anterior open bite and gingival recession in tooth UL1. This case report demonstrates how a multidisciplinary approach, which includes orthodontic treatment, periodontal plastic surgery, guided bone regeneration, and an implant-supported crown, can effectively restore both function and aesthetics for the patient. Additionally, a narrative review of the literature is presented alongside the case presentation. CPD/Clinical Relevance This case report illustrates a multidisciplinary approach that effectively addresses complex cases in aesthetic dentistry.

Although the restoration of non-carious cervical lesions (NCCLs) may seem straightforward, it is the restorative therapy with the highest rate of clinical failure. This may be due to marginal discolouration, fracture or loss of the restoration, the appearance of secondary caries or aggravation or the creation of periodontal problems. In view of this, it is essential to take into account the difficulties in achieving these restorations and addressing these by choosing the most suitable materials and techniques. This review summarizes the current understanding of restorative management of NCCLs with composite resin and discusses factors affecting efficacy and difficulties encountered during the implementation in order to propose an approach that leads to a higher success rate and longevity of the restoration. CPD/Clinical Relevance Choosing a protocol that achieves a high success rate for the restorative management of NCCLs with composite resin is important.

The restoration of a root filled tooth is a common procedure in dental practice and should only be undertaken after a thorough assessment of the existing root filling. Of the many root canal fillings that are seen, some will meet the requirements of an optimal filling, and some will be deemed sub-optimal. Some will detected following symptoms presented by the patient and some will appear on routine radiographic assessment. Some will have been present for many years and some for a relatively short period of time. The assessment and management of the sub-optimal root filling present challenges for the general dental practitioner; in understanding the limitations of radiographic appearance, in the ability to improve the existing sub-optimal filling, and in the restorative process required to bring the tooth to aesthetic and/or functional use. CPD/Clinical Relevance All root fillings require thorough assessment and management.

The maxillary sinuses are frequently seen on intra-oral and panoramic radiographs taken in general dental practice. Variation in normal appearances of the maxillary sinuses can be mistaken for disease and a wide range of odontogenic and non-odontogenic diseases can change sinus appearance. This means that a systematic approach is needed when interpreting radiographs, including those of the sinuses. The article provides examples of normal anatomy and illustrations of some of the more common abnormal findings, as well as suggestions for management in these cases. CPD/Clinical Relevance The maxillary sinuses are visible on radiographs in general dental practice, meaning that practitioners need to be able to recognize features of health and disease in them.

Dental implants placed immediately into single-rooted extraction sockets have been well documented over the years. More recently there has been an increase in the publications looking at immediate implants in molar extraction sites. The advantages of reducing treatment times and limiting the number of surgeries helps with patient acceptance and is also advantageous for the surgeon. There are also clinical advantages of improved pink aesthetic scores and reduced food packing for the definitive restorations. This case report demonstrates the techniques used in achieving a predictable outcome in immediate molar implant treatment. CPD/Clinical Relevance The advantages and the methods used for placing an implant into a molar extraction socket and restoring it are discussed.

Natal and neonatal teeth newborns have a prevalence range of 1:2000–3500 live births. Depending on the extent of consequent mobility, natal and neonatal teeth can pose a risk of aspiration, or cause trauma to the mother during nursing or intra-oral ulceration in the infant. A retrospective audit of paediatric dentistry clinics was conducted covering December 2019 to March 2023, identifying infants who were referred shortly after birth (up to 3 months of age). Thirty infants were identified with a range of oral diagnoses. A majority had natal or neonatal teeth (n=19), followed by soft tissue anomalies such as eruption cyst, Bohn's nodules, Epstein's pearls, and an alveolar notch. Natal and neonatal teeth are rare, but can be distressing for parents. Cases were managed with reassurance and monitoring, or extraction of natal/neonatal teeth in certain circumstances. A management flow chart is presented to help neonatal teams and general dental practitioners to determine the most appropriate course of action. CPD/Clinical Relevance Depending on the extent of mobility, natal and neonatal teeth can pose a risk of aspiration or result in trauma to the mother during nursing.

Modern dental implantology dates back to 1952 when Professor Per-Ingvar Brånemark discovered that titanium can enable bone to metal integration, without an intervening fibrous tissue layer. The first titanium dental implant was reported as being placed in 1965. Dental implants have since evolved and are used for single teeth, fixed bridgework, immediate loading and full-arch reconstructions for edentulous patients and in the management of the head and neck cancer. The result of this evolution is a range of site-specific dental implants. This article provides an overview of the role of the different site-specific implants within the maxillary/mandibular bony envelope, and the place they may have in dental rehabilitation. The focus will be on the extremes of implant size category, described as minis and maxes for the purpose of this overview. CPD/Clinical Relevance: An awareness of different implant morphology for specific sites is useful.

Oral lichen planus (OLP) has an estimated global prevalence of 1% and is considered to be a disorder that requires lifelong surveillance. Clinical subtypes of OLP include reticular, atrophic, papular, plaque-like, ulcerative and bullous variants. OLP can present with desquamative gingivitis, and women may have associated vulval and/or vaginal involvement. Diagnosis of OLP is based on clinical and histopathological findings. Reticular and plaque-like OLP tends to be asymptomatic and seldom requires treatment. Ulcerative and atrophic OLP can generally be managed with topical corticosteroids. Severe and widespread ulcerative lesions may require systemic drugs. CPD/Clinical Relevance: General dental practitioners need to be able to recognize the different clinical presentations of oral lichen planus and refer appropriately.

Despite their relatively low incidence, unerupted maxillary incisors have a sizeable impact on a patient's function, phonetics and aesthetics. Management of these teeth commonly involves surgical exposure and orthodontic traction. This report describes a previously unreported intra-operative finding. During surgical exposure of an unerupted maxillary incisor, the pulpal tissue was found to be continuous with the oral mucosa. Subsequent separation of the tissues resulted in pulpal necrosis, requiring endodontic management. Awareness of unique complications is required. To ensure valid consent, all risks and alternative treatment options for these must be clearly communicated. CPD/Clinical Relevance: Despite meticulous planning, not all intra-operative complications can be anticipated, hence good patient communication is important.

The aim of restorative dentistry, by and large, is to restore damaged, ill shaped, malpositioned, or malfunctioning teeth so that they look good and function well. This objective can be achieved by either direct or indirect restorations; sometimes just a single tooth may be involved, or at other times several teeth may be involved, commonly when there is tooth wear. The dental practitioner is faced with having to make decisions, on a frequent basis, as to which to choose. While it is good to have a choice, it is essential that the practitioner understands the risks and the benefits of each option, and the skill and expertise required for their successful execution. It is also important to have a protocol for assessing distressed teeth so that an informed decision can be made. This can then be discussed with the patient. CPD/Clinical Relevance: The choice between a direct or indirect restoration and the material to be used for a particular tooth is a frequent challenge for dental practitioners.

Melkerrson-Rosenthal syndrome is a disease with a triad of clinical features: unilateral facial palsy; orofacial swelling; and a fissured tongue. It is a subset of orofacial granulomatosis. The authors present a case report to increase awareness of the syndrome among general dental practitioners, who may be the first to encounter its manifestations. The management and outcomes of this case are discussed. National and international guidance is lacking owing to the rarity of the condition. CPD/Clinical Relevance: Early recognition of manifestations of the syndrome is important for timely diagnosis, appropriate referral, and multidisciplinary management to prevent complications.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by a spectrum of symptoms of inattention, hyperactivity and/or impulsivity. Children with ADHD present with a number of behavioural challenges which can potentially increase caries risk, dental trauma incidence and non-compliance in the dental setting. CPD/Clinical Relevance: This article aims to increase the awareness and understanding of ADHD and provide management strategies for clinicians to facilitate successful dental visits.