As in other dental specialties, endodontology has established a specialization and an educational programme. In 1990 a 3 year post-academic programme in endodontology was established at the Academic Centre for Dentistry in Amsterdam. Students have to be present 3 days a week. Additionally, they have to perform a substantial amount of self study. The education will enable the endodontic specialist to perform his or her clinical handling and thinking scientifically and by an evidence-based approach. The education will allow the specialist treating his patients optimally, but also sharing his knowledge with colleagues or participating in academic education and research.

Post-academic dental specialties 15. Prevention of coronal leakage after placement of lining cement One of the main origins of unsuccesful endodontic treatment is coronal leakage. In the prevention of coronal leakage a good sealing restoration seems mandatory. The effect of 2 types lining cement used as coronal barrier on filled root canals was studied over time. Fifty extracted human canines were prepared and filled by gutta-percha with a quantifiable initial coronal leakage. After placement of the lining cements in 2 groups of 20 canines, leakage was assessed at 96 hours and at 26 weeks and compared with the leakage in a control group of 10 canines. Placement of a coronal barrier of lining cement on the orifice of the root canal after endodontic treatment revealed a significant reduction of coronal leakage. In this study leakage decreased over time.

Since the introduction of composites and bonding in orthodontics, the possibilities of aligning impacted teeth into the dental arch after a surgical intervention, have remarkably increased. There are 4 important treatment techniques. The closed-eruption technique includes bracket-bonding to and ligating of the exposed tooth, followed by repositioning of the mucosal flap. The disadvantage of the method is the uncontrollable orthodontic force on the non-visible tooth during orthodontic extrusion. The open-eruption technique aims at keeping the exposed tooth visible, followed by spontaneous eruption. However, the exposure appears often as a radical exposure with unfavourable gingival consequences. The open eruption technique with apical positioned mucosal flap is designed to expose teeth highly buccally impacted. The mucosal graft may cause a typical thick, stretched and not aesthetically acceptable gum after orthodontic treatment, even in case of using a split-thickness graft. The modified window technique is an open eruption technique with minimal exposure, resulting in immediate eruption. If orthodontic treatment is required, the tooth is no longer impacted. The success rates of the 4 techniques vary from 75 until 99%. Study of the literature reveals insufficient scientific evidence in favour of 1 treatment technique. However, independent of the surgical technique applied, general practitioners play a crucial role in diagnostics of eruption failures and timely referral to an orthodontist.

Bisphosphonates are generally administered either orally or intravenously. Orally administered bisphosphonates are primarilly used in the treatment of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, and Paget’s disease. When orally administered, only about 1% is absorbed from the tractus from the tractus digestivus. With intravenous administration, higher blood levels levels are reached. Intravenously administered bisphosphonates are used in the treatment of hypercalcaemia, Kahler’s disease, and bone metastases of other malignancies. A few cases of osteonecrosis of the jaw(s) are seen especially when more powerful bisphosphonates are administered intravenously. This osteonecrosis is most often provoked by means of an invasive oral treatment. Bisphosphonate-associated osteonecrosis is very difficult to treat. Therefore, dental preventive measures and treatment of dental foci and other inflammations are recommended before starting bisphosphonate therapy.

Bisphosphonate-associated osteonecrosis of the jaws 2. Six case reports The diagnostic procedures and the treatment of 6 patients with bisphosphonate-related osteonecrosis of the jaw are reported. During recent years, bisphosphonates have been prescribed with increasing frequency. The main pharmacological effect is the inhibition of bone resorption, mediated by osteoclast activity impairment. The osteonecrosis is usually very therapy resistant and may cause considerable morbidity. Therefore, oral screening is indicated and focal oral infections should be eradicated prior to therapy with bisphosphonates. If bisphosphonate therapy has already been started, invasive oral procedures should be restricted to unavoidable treatment. When invasive treatment can not be avoided, the risk of osteonecrosis may be reduced by primary wound closure, antibiotic prophylaxis and adequate oral hygiene measures, supplemented by using a chlorhexidine mouthrinse. Cessation of smoking is recommended.

The cases presented show that bisphosphonate-induced osteonecrosis of the jaw is difficult to treat. Recently, a classification of bisphosphonate-induced osteonecrosis of the jaw based on clinical appearance was published. On the basis of this classification the seriousness of the osteonecrosis can be evaluated and a method of treatment determined. The common opinion is that treatment should be as conservative as possible. This means that treatment should have as its objective the prevention of the spread of the disease by means of antibiotics and disinfectant mouthwash. Sharp bony edges may be trimmed. Extensive surgical treatment should be reserved for those rare cases in which the osteonecrosis is progressive.

Kawasaki disease is an acute vasculitis that occurs especially in young children. Because there is no specific laboratory test available, diagnosis has to be made on the basis of clinical characteristics: prolonged fever, oropharyngeal changes, conjunctival injection, erythema and edema of hands and feet, rash, and cervical lymphadenopathy. Without treatment there is a 25% chance of cardiac complications, especially aneurysms of the coronary arteries. Early treatment with intravenous immunoglobulin reduces this risk to 5%. Accurate diagnosis and therapy is crucial. Kawasaki syndrome has been reported in all racial groups with the highest incidence in Japanese children. Together with the fact that the disease is more common in boys this indicates that genetic factors play an important role in determining susceptibility to a (probably infectious) trigger. In spite of 40 years of intensive scientific research, the cause of Kawasaki disease still remains unknown.