Critically Appraised Topics An approach to pre-doctoral research opportunities

UIC Clinic & Research Day 2013

Fourth Annual Competition

L&L Agenda

Objectives

Parameters

How to find cases

CaseCAT Poster Template

CaseCAT Worksheet

CaseCAT Literature Worksheet

Judging Criteria

Once you have identified a case

Contact information

Objectives

To provide an opportunity for pre-doctoral

students to engage in a patient based study to

the level of scientific inquiry

To facilitate the transformation of a patient

based study to a case presentation that can be

presented at Clinic and Research Day

Parameters

How were treatment plans or outcomes for your patient affected by:

Treatment procedure

Patient health concerns

Therapeutic problems concerning patient

Unusual medications

Treatment consideration for medically compromised or patients with disabilities

Example: Blood pressure medication that

causes xerostomia What are causes, how do you evaluate, how do you treat?

Where do I find cases?

1. Portfolio

On medically compromised patients i.e. diabetes, hypertension

Patients on 3 or more medically significant therapeutic medications

2. Screening Clinic/Urgent Care

Diagnosis of an interesting patient issue

3. Rotations with specialty clinics

Working with residents

Examples include: Ortho (craniofacial anomaly), Perio (diabetes), Endo (implants)

Important Elements

to Consider

Patient issue exemplifies problem

Thoughtful description of case

Adequate Documentation (must be de-identified) Photos and radiographs

Axium page with charting

Patient medical, dental history, chief complaint

Differential Diagnosis In many cases already preexisting diagnosis

Develop case to level of CAT Faculty, journals and internet as resources

IRB Issues Must be single case, case series not acceptable

Situation of Concern (Calibri font size 60) Student Name

Advisor

CASE SCENARIO

CAT 1 CAT 2 CAT 3

CRITICAL QUESTION CASE SIGNIFICANCE Student Summary

Place the critical elements of your case here… e.g., Chief Complaint, Hx, AXIUM data, photos, etc. (preferably in font Calibri - minimum size 20)

Type your searchable question here… (preferably in font Calibri - minimum size 20)

Type your CAT here… (preferably in font Calibri - minimum size 20)

Type your CAT here… (preferably in font Calibri - minimum size 20)

Type your CAT here… (preferably in font Calibri - minimum size 20)

Type your bottom line here… (preferably in font Calibri - minimum size 20)

MESH Terms:

P: I:

C: O:

Place the critical elements of your case here… e.g., Chief Complaint, Hx, AXIUM data, photos, etc. (preferably in font Calibri - minimum size 20)

P… I… C… O…

Terms…

FUTURE DIRECTIONS Write future directions here… (preferably in font Calibri - minimum size 20)

CaseCAT

Worksheet

CaseCAT Worksheet

Should I use CavitTM, IRMTM, or KetacFillTM? Student: Michael P. Munaretto

Advisor: Bradford Johnson, DDS MHPE, UIC Department of Endodontics

CASE SCENARIO

CAT (1) CAT (2) CAT (3)

CRITICAL QUESTION CASE SIGNIFICANCE

29 y/o healthy female has full mouth radiographs taken as part of comprehensive oral examination. Periapical Radiolucencies are seen on teeth #4 and #5 (see arrows below).

MESH Terms:

Exam: EOE WNL. IOE reveals large DO amalgam restorations present on both teeth. The following clinical tests were performed:

P- Patients receiving root canal therapy

I- Temporary restorative material (Cavit, IRM, or KetacFill [GI])

C- Definitive restoration

O- Durability and resistance to coronal microleakage

Tooth Cold EPT Perc Palp Probing Mobility

3 WNL 31/80 WNL WNL 323B 323L 0

4 NR 80/80 WNL WNL 323B 323L 0

5 NR 80/80 WNL WNL 323B 323L 0

6 WNL 26/80 WNL WNL 323B 323L 0

Diagnosis: #4 and #5 Necrotic Pulp, Asymptomatic (Chronic) Apical Periodontitis

Treatment Plan: Non-surgical RCT #4 and #5. Multiple visits will be required.

For patients receiving root canal therapy, which temporary restorative material (Cavit, IRM, or KetacFill GI) compares most favorably to the properties of the definitive restoration as measured by durability and resistance to coronal microleakage?

FUTURE DIRECTIONS Write future directions here… (preferably in font Calibri - minimum size 20)

CaseCAT Worksheet

Should I use CavitTM, IRMTM, or KetacFillTM? Student: Michael P. Munaretto

Advisor: Bradford Johnson, DDS MHPE, UIC Department of Endodontics

CASE SCENARIO

CAT (1) CAT (2) CAT (3)

CRITICAL QUESTION CASE SIGNIFICANCE

29 y/o healthy female has full mouth radiographs taken as part of comprehensive oral examination. Periapical Radiolucencies are seen on teeth #4 and #5 (see arrows below).

Beach et al. “Clinical Evaluation of Bacterial Leakage of Endodontic Temporary Filling Materials.” Journal of Endodontics 22:9 pp459-462. 1996. Methods: 51 human teeth received RCT in vivo. After obturation a sterile paper disk was placed below a 4 mm filling of Cavit, IRM, or TERM. Three weeks later the patients were recalled, the fillings were removed, and the paper disks were analyzed for bacterial growth. Results/Conclusion: 1/18 IRM samples showed bacterial growth, whereas 0/19 Cavit samples showed growth. No significant difference was found between IRM and Cavit. Validity/Applicability: Restoration type was randomly assigned. Follow up was 100%. in vivo study. 3 week follow-up realistic at UIC COD. Level of Evidence: 2 (Randomized Controlled Trial)

MESH Terms:

Exam: EOE WNL. IOE reveals large DO amalgam restorations present on both teeth. The following clinical tests were performed:

P- Patients receiving root canal therapy

I- Temporary restorative material (Cavit, IRM, or KetacFill [GI])

C- Definitive restoration

O- Durability and resistance to coronal microleakage

Tooth Cold EPT Perc Palp Probing Mobility

3 WNL 31/80 WNL WNL 323B 323L 0

4 NR 80/80 WNL WNL 323B 323L 0

5 NR 80/80 WNL WNL 323B 323L 0

6 WNL 26/80 WNL WNL 323B 323L 0

Diagnosis: #4 and #5 Necrotic Pulp, Asymptomatic (Chronic) Apical Periodontitis

Treatment Plan: Non-surgical RCT #4 and #5. Multiple visits will be required.

For patients receiving root canal therapy, which temporary restorative material (Cavit, IRM, or KetacFill GI) compares most favorably to the properties of the definitive restoration as measured by durability and resistance to coronal microleakage?

Root Canal Therapy; Dental Restoration, Temporary; Leakage

Barthel et al. “Leakage in Roots Coronally Sealed with Different Temporary Fillings.” Journal of Endodontics 25:11 pp 731-734. 1999. Methods: 103 extracted single-rooted teeth received RCT and were then filled with either Cavit, IRM, GI, Cavit/GI, or IRM/GI. Teeth were then immersed into a two-chamber system which was inspected daily over a 30-day period for bacterial microleakage. Results/Conclusion: GI gave the best seal against bacteria (1/20 samples leaked), whereas Cavit gave the poorest seal (13/20 samples leaked). 11 out of 20 IRM samples leaked. Validity/Applicability: Results of in vitro studies cannot directly be applied to clinical practice. However, all available filling materials to UIC COD students were tested. Level of Evidence: 6 (Preclinical study) .

Naoum & Chandler. “Temporization for Endodontics.” International Endodontic Journal 35:pp 964-978. 2002. Methods: A literature review was performed using MEDLINE and contemporary textbooks to assess various endodontic temporary filling materials and to make clinical recommendations. Results/Conclusion: Cavit possesses favorable marginal seal but inferior mechanical properties compared to IRM. Studies have shown that IRM also provides a favorable marginal seal, especially when the powder: liquid ratio is decreased. GI is more costly, but has been found to be antibacterial and to have a superior seal; thus it may be used for cases of long-term temporization. Validity/Applicability: Authors did not provide a detailed selection criteria for articles reviewed. Level of Evidence: 5 (Expert Opinion)

FUTURE DIRECTIONS Write future directions here… (preferably in font Calibri - minimum size 20)

CaseCAT Worksheet

Should I use CavitTM, IRMTM, or KetacFillTM? Student: Michael P. Munaretto

Advisor: Bradford Johnson, DDS MHPE, UIC Department of Endodontics

CASE SCENARIO

CAT (1) CAT (2) CAT (3)

CRITICAL QUESTION CASE SIGNIFICANCE

29 y/o healthy female has full mouth radiographs taken as part of comprehensive oral examination. Periapical Radiolucencies are seen on teeth #4 and #5 (see arrows below).

Beach et al. “Clinical Evaluation of Bacterial Leakage of Endodontic Temporary Filling Materials.” Journal of Endodontics 22:9 pp459-462. 1996. Methods: 51 human teeth received RCT in vivo. After obturation a sterile paper disk was placed below a 4 mm filling of Cavit, IRM, or TERM. Three weeks later the patients were recalled, the fillings were removed, and the paper disks were analyzed for bacterial growth. Results/Conclusion: 1/18 IRM samples showed bacterial growth, whereas 0/19 Cavit samples showed growth. No significant difference was found between IRM and Cavit. Validity/Applicability: Restoration type was randomly assigned. Follow up was 100%. in vivo study. 3 week follow-up realistic at UIC COD. Level of Evidence: 2 (Randomized Controlled Trial)

MESH Terms:

Exam: EOE WNL. IOE reveals large DO amalgam restorations present on both teeth. The following clinical tests were performed:

P- Patients receiving root canal therapy

I- Temporary restorative material (Cavit, IRM, or KetacFill [GI])

C- Definitive restoration

O- Durability and resistance to coronal microleakage

Tooth Cold EPT Perc Palp Probing Mobility

3 WNL 31/80 WNL WNL 323B 323L 0

4 NR 80/80 WNL WNL 323B 323L 0

5 NR 80/80 WNL WNL 323B 323L 0

6 WNL 26/80 WNL WNL 323B 323L 0

Diagnosis: #4 and #5 Necrotic Pulp, Asymptomatic (Chronic) Apical Periodontitis

Treatment Plan: Non-surgical RCT #4 and #5. Multiple visits will be required.

For patients receiving root canal therapy, which temporary restorative material (Cavit, IRM, or KetacFill GI) compares most favorably to the properties of the definitive restoration as measured by durability and resistance to coronal microleakage?

Root Canal Therapy; Dental Restoration, Temporary; Leakage

Barthel et al. “Leakage in Roots Coronally Sealed with Different Temporary Fillings.” Journal of Endodontics 25:11 pp 731-734. 1999. Methods: 103 extracted single-rooted teeth received RCT and were then filled with either Cavit, IRM, GI, Cavit/GI, or IRM/GI. Teeth were then immersed into a two-chamber system which was inspected daily over a 30-day period for bacterial microleakage. Results/Conclusion: GI gave the best seal against bacteria (1/20 samples leaked), whereas Cavit gave the poorest seal (13/20 samples leaked). 11 out of 20 IRM samples leaked. Validity/Applicability: Results of in vitro studies cannot directly be applied to clinical practice. However, all available filling materials to UIC COD students were tested. Level of Evidence: 6 (Preclinical study) .

Naoum & Chandler. “Temporization for Endodontics.” International Endodontic Journal 35:pp 964-978. 2002. Methods: A literature review was performed using MEDLINE and contemporary textbooks to assess various endodontic temporary filling materials and to make clinical recommendations. Results/Conclusion: Cavit possesses favorable marginal seal but inferior mechanical properties compared to IRM. Studies have shown that IRM also provides a favorable marginal seal, especially when the powder: liquid ratio is decreased. GI is more costly, but has been found to be antibacterial and to have a superior seal; thus it may be used for cases of long-term temporization. Validity/Applicability: Authors did not provide a detailed selection criteria for articles reviewed. Level of Evidence: 5 (Expert Opinion)

Few in vivo studies and no systematic reviews exist studying this topic. However, from the available evidence the following conclusions can be drawn:

1. Cavit provides an adequate seal over at least 3 weeks as revealed by an in vivo study (1). However, due to its poor mechanical properties, its use should be reserved only for conservative accesses where occlusal forces are minimal (3).

2. IRM provides an adequate seal over at least 3 weeks as revealed by an in vivo study (1). Its mechanical properties are superior to Cavit and it is therefore indicated for whenever the tooth will be regularly subjected to occlusal forces. As the powder: liquid ratio is decreased, the seal improves (at the expense of mechanical properties). (3)

3. GI has been found in an in vitro study to have a superior seal to Cavit and IRM (2). Because of this, GI has been recommended for longer term temporization (3).

4. Studies have recommended that a definitive restoration be placed as soon as possible following obturation (2, 3).

Direct Pulp Capping: Mineral Trioxide Aggregate (MTA) or

Calcium Hydroxide (Dycal)? Student: Andrea Venizelos

Advisors: Satish Alapati, BDS,MS,PhD; Bradford Johnson, DDS, MHPE, UIC Department of Endodontics

CASE SCENARIO

CAT 1 CAT 2 CAT 3

CRITICAL QUESTION CASE SIGNIFICANCE Student Summary

During caries excavation on a mature adult tooth a pinpoint pulp exposure is noticed and pulp capping is indicated.

During caries excavation on a mature adult tooth a pinpoint pulp exposure (<1mm) is noticed, for

increased survival of the tooth, which material should be used for pulp capping: MTA (Mineral

Trioxide Aggregate) or Calcium Hydroxide (Dycal)?

Olsson et al. “Formation of a Hard Tissue Barrier After Pulp Capping in Humans. A Systematic Review.” International Endodontic Journal 36 pp 429-442. 2006. Methods: A PubMed and Central literature search with specific terms were made. Level of evidence of the publications was assessed. Results/Conclusion: 21 publications remained after interpretation. None had a high level of evidence, one had moderate level of evidence, and 20 had a low level of evidence. Evidence grade was determined to be insufficient. Does not imply that there is no effect of a pulp capping procedure, but rather a need for high-quality studies. Capping material included calcium hydroxide, bonding materials, Vitrebond, synthetic hydroxyapatite, isobutyl cyanoacrylate, and MTA. Validity: Had valid inclusion criteria, and evaluated LOE. LOE: 1 (Systematic Review)

Aeinehchi et al. “Mineral Trioxide Aggregate (MTA) and Calcium Hydroxide as Pulp-Capping Agents in Human Teeth: A Preliminary Report.” International Endodontic Journal 36 pp 225-231. 2003. Methods: 22 maxillary third molars were subjected to mechanical pulp exposure. Pulp capping material was either MTA or calcium hydroxide, covered with ZOE and restored with amalgam. Extractions were after periods of 1 week, 2 months, and 6 months. Results/Conclusion: Less inflammation, hyperemia and necrosis plus thicker dentinal bridge and more common odontoblast layer formation with MTA was found than with calcium hydroxide. Validity: Direct pulp capping material was randomly assigned. Small sample size, large drop-out of patients. LOE: 2 (Randomized Controlled Trial)

Nair et al. “Histological, Ultrastructural and Quantitative Investigations on the Response of Healthy Human Pulps to experimental Capping with Mineral Trioxide Aggregate: A Randomized Controlled Trial.” International Endodontic Journal 42 pp 422-444. 2009. Methods: A pulpal exposure was made in 35 healthy maxillary third molars from 23 patients. Pulp capping material was either MTA or Dycal. 33 of these teeth were histo-morphologically processed. Cavities were restored with IRM. Extractions were after periods of 1 week, 1 month, and 3 months. Results/Conclusion: Pulp exposures treated with MTA were essentially free from inflammation and covered with hard tissue bridges. Teeth treated with Dycal had less hard tissue formation, more pulpal inflammation, and seepage of material into the pulp. Validity: Direct pulp capping material was randomly assigned. Follow up was 100% LOE: 2 (Randomized Controlled Trial)

Few in vivo studies are available on this topic. However, from the available evidence the following conclusions can be drawn: 1. Calcium hydroxide does not adhere to the dentin and lacks the ability to seal. Seepage of material into the pulp is probable. Hard tissue bridges that form are incomplete and present with tunnel defects that act as a pathway for microleakage. 2. Pulp defects treated with MTA have less inflammation, less hyperemia, more stable hard tissue bridges with increased thickness, and are free from tunnel defects. MTA shows greater ability to provide a fluid-tight seal. 3. MTA has a much greater cost than calcium hydroxide. 4. There is a need for more high-quality studies for MTA to definitively be the material of choice for direct pulp capping.

MESH Terms:

Exam: EOE WNL. IOE reveals large DBIL carious lesion.

P… Adult with pinpoint pulp exposure (<1mm) I…Direct pulp capping C…Material ((Mineral Trioxide Aggregate (MTA) or Calcium Hydroxide (Dycal)) O…Increased survival of tooth

Dental Pulp Capping; Pulpal Response; Mineral Trioxide Aggregate; Calcium Hydroxide

Tooth Cold EPT Perc Palp Probing Mobility

7 WNL 35/80 - - 323B/323L 0

8 WNL 24/80 - - 324B/423L 0

9 WNL 36/80 - - 423B/323L 0

10 WNL 32/80 - - 323B/323L 0

Diagnosis: #8 Normal Pulp with Normal Periapical

Treatment Plan: Excavate caries and restore. RCT not indicated

Ideal Luting Agent for a Zirconia Abutment Student: Shivam Patel

Advisor: Dr. Satish Alapati

CASE SCENARIO

CAT 1 CAT 2 CAT 3

CRITICAL QUESTION CASE SIGNIFICANCE Student Summary

For a patient receiving an imlpant in an esthetic zone with a Zirconia based abutment, what is the ideal luting agent that will provide adequate retention to prevent dislodgement?

Nejatidanesh F, Savabi O, Shahtoosi M. “Retention of implant-supported zirconium oxide ceramic restorations using different luting agents.” Clin Oral Implants Res. 2011 Nov 14.

Methods: 20 ITI abutments (5.5mm height) and ITI implant analogs mounted to acrylic blocks. 90 ZrO2 copings (Al2O3 abraded). Copings conditioned in artificial saliva and thermocycled and cemented w/ various cements.

Results/Conclusion: Resin based and RMGI luting agents are most retentive. Cement selection should be based upon site as well as option for retrievability.

Validity/Applicability: Study limitations were monotonic static load, in vivo forces have dynamic loading. Fatigue of cements under load not analyzed but data presented and each specimen only subjected to one variable (luting agent).

Level of Evidence: Level 5 – Bench top research

Kim, Min-Jeong, et al. "Shear Bond Strengths of various Luting Cements to Zirconia Ceramic: Surface Chemical Aspects." Journal of dentistry 39.11 (2011): 795-803. .

Methods: Mutiple cement types were bonded to sandblasted ZrO2 (Lava). Specimens were stored in water at 37 degrees C and other ½ thermocycled. Shear bond strengths and surface energy parameters were recorded.

Results/Conclusion: Panavia F 2.0 and Principle produced higher bond strengths than other cements w/ no significant differences before or after thermocycling.

Validity/Applicability: The study suggests that surface energy parameters should be important considerations in determining which luting agent should be utilized for proper adhesion. Various surface treatments should be incorporated for comparison

Level of Evidence: Level 5 – Bench top research

Ekfeldt A, Fürst B, Carlsson GE. “Zirconia abutments for single-tooth implant restorations: a retrospective and clinical follow-up study.” Clin Oral Implants Res. 2011 Nov;22(11):1308-14.

Methods: Part 1 – Retrospective evaluation of 130 patients w/ 185 STI restorations w/ ZrO2 abutments. Part 2 – Clinical exam of 25 patients w/ 40 restorations placed >3 yrs ago. 93 cemented w/ zinc phosphate, 1 w/ resin cement, 1 w/ TempBond

Results/Conclusion: ZrO2 abutments had low rate of technical and biological complications, soft tissue responded well.

Validity/Applicability: Multiple focus parameters w/ short follow up but vast data collection. Protocol for surgery and restoration standardized and positive 3-5 year success.

Level of Evidence: Low Level 3 – Retrospecitve analysis and clinical follow up study

Many studies have been conducted on ZrO2

plates/discs and the vast majority of search results were in vitro studies. Systematic reviews were not available as the material in question is still fairly new in the scope of dental practice. The topic has helped me realize the importance of material science and its place in dentistry. Bonding concepts, biocompatibility, and physical/chemical properties are factors that contribute a great deal to success within the oral cavity. Based on my research resin based luting agents are the best candidates for cementation onto a ZrO2 substrate such as an implant abutment. Air abrasion, priming, and trebochemical treatments are all areas for future research to determine the best alternative to increase bond strengths in the zirconia material without compromising its physical/chemical integrity.

MESH Terms:

24 y/o hispanic female presents after traumatic avulsion #25. She would like to have a fixed restoration, preferably a dental implant. Esthetics and function are her primary concern. IOE reveals a thin soft tissue biotype which may have an adverse outcome if stock/titanium abutment is utilized.

P – Patient receiving a zirconia implant abutment I – Resin based luting cement C – Conventional cement O – Adequate bond strength between final restoration and abutment

Zirconia abutment Luting Agent

Implant Bonding

Mean microtensile bond strengths for ceramic bonded to composite groups.

Mean (standard deviation) of dislodgining forces of the studied cement (N) groups.

CaseCAT

Literature

Worksheet

Evaluation Sheet

Once you have identified a case:

Identify a mentor

Primary Contact: Group Practice Manager

All project Titles should be e-mailed or turned in to

Katherine Long at longka@uic.edu

by January 14, 2013

Talk to previous participants

Questions?

CaseCAT contacts:

Dr. Marucha marucha@uic.edu

Dr. Knight gwknight@uic.edu

Mat Wietecha mwietec2@uic.edu