Quintessence International, 09/2004

In my previous editorial I bemoaned the fact that multiple economic and regulatory forces acting on dentistry do not allow the average practitioner to deliver the highest quality care for his or her patients. I think it would be wrong to point out all the problems without making some suggestions for their solutions. The first factor contributing to fee escalation is the rapid progression of technology and its high cost. While we can't stop progress, we can be selective about new techniques and devices used in our practices, thus, reducing the need for fee increases. We can make sure that someone has tested these products before we use them. The best solution to governmental interference is to eliminate most of it. History shows that increases in governmental intervention lead to reduced quality of care. If you don't believe it, look at medicine. Our medical friends are a few years ahead of us in these terms, and the results have been disastrous. Regardless of what politicians say, no country can pay for optimal care for everyone. The sooner that this is admitted, the sooner we are likely to find better solutions. As to private insurance, let's get realistic. With the exception of those individuals who have suffered facial trauma in an accident, our patients rarely get adequate coverage. We should cut out the middleman and simply have negotiations done between the dentist and the patient. This would necessitate giving the patient the economic ability to negotiate. One method would be the use of medical savings accounts for dentistry. Another would be to have a limited number of dollars for dental coverage provided by corporations, which are controlled by the patient, not a third party. The increasing number of lawsuits can be handled by a combination of effective self-policing and tort reform. It is very easy to blame all of the litigation on lawyers, but it is not all their responsibility. Individual dentists can keep better records, keep up with their education, and refer when appropriate, thus reducing the number of lawsuits. Serious tort reform could go a long way toward discouraging frivolous lawsuits. For tort reform to work without having patients suffer, organized dentistry needs to step up and actually get serious about regulating its members. Self-policing, if handled correctly, can be effective but needs to more closely resemble that of our medical colleagues. Another important step is to change the character and location of the average dental practice. Tax incentives could be provided that would encourage dentists to go into underserved areas, while tax penalties could be levied against those not in multidentist offices. I understand that the probability of all these solutions occurring is extraordinarily remote. But if we are honest and work together, we can waste less money and apply those dollars toward delivering the highest quality care. Are you? Thomas G. Wilson, DDS Editor-in-Chief

A case report describing a technique for the restoration of endodontically treated primary maxillary incisors with resin composite short posts and celluloid strip crowns in a 3-year-old boy is presented. The technique offers the advantages of using one restorative material, improving esthetics, and reducing chairtime and costs.

Objectives: Transient sensitivity during bleaching is generally reported to affect 67% of patients. While most people tolerate this sensitivity, some find it impossible to continue treatment. The purpose of this study was to determine the safety and efficacy of an experimental, low-sensitivity bleaching agent. Method and materials: Twenty-two participants bleached for a minimum of 6 hours per night over a 2-week period. The bleaching agent used, Experimental Product E, is a 10% carbamide peroxide gel containing potassium nitrate and sodium fluoride. Evaluations were performed at baseline and 1, 2, 13, and 26 weeks. Color change was measured using a value-ordered Vita classic shade guide and a colorimeter. Sensitivity of the teeth, gingiva, tongue, and/or throat was measured daily using a patient log. Results: The median color change after 2 weeks was eight tabs. Approximately 36% reported sensitivity during the active whitening phase of the study. As a group, participants reported sensitivity during 13.7% of the total days spent whitening. Conclusion: Experimental Product E was shown to be safe. Participants experienced minor sensitivity during the active bleaching phase only. Experimental Product E was shown to be an effective bleaching agent for the subjects tested in this study.

Objective: The purpose of this study was to determine and compare the incidence, location, and size of accessory foramina in the furcation region of permanent and primary molars. Method and materials: A random sample of 100 extracted human permanent maxillary and mandibular first and second molars (25 teeth of each type) and a random sample of 100 extracted human primary maxillary and mandibular molars (50 teeth of each type) were used. The crowns and roots of each tooth were removed at a point 1.5 mm apical to the external furcation region, and a second cut was made at a point 1 mm apical to the cementoenamel junction. The specimens were examined using scanning electron microscopy at magnifications ranging from 310 to 31,250. The incidence, location, and size of accessory foramina were documented and statistically analyzed. Results: Of the 100 permanent molars examined, 79% had accessory foramina with diameters ranging from 10 µm to 200 µm. Accessory foramina were present in 94% of the primary molars, with diameters varying from 10 µm to 360 µm. The incidence of accessory foramina was significantly higher in primary than in permanent molars. Conclusion: The presence of accessory foramina with large diameters may imply that an inflammatory process can spread from pulpal to periodontal tissues and vice versa.

The aim of this study was to evaluate the relationship between the accumulation of interleukins IL-1ß, TNF-α, IL-8, and chemokine RANTES (Regulated upon Activation Normal T-cell Expressed and Secreted) in gingival fluid and periodontal support tissues in patients with periodontitis. A review is also provided of apoptotic processes as events of major importance, highlighting the presence of TUNEL cells and ultrastructural morphologic changes associated with cell apoptosis. There appears to be further evidence to support the important role of inflammation control. Cytokines may be considered as markers of the progression and severity of periodontitis as well as indicators of an appropiate response to treatment. However, further studies are needed to support and characterize this concept.

Twenty implants with sand-blasted, large-grit, acid-etched (SLA) surfaces (ITI Dental System) were followed up for a period of 12 months, during which the following clinical criteria were evaluated: (a) absence of persistent clinical symptoms (pain, strange sensations, or paresthesia) after the placement of implants; (b) absence of recurring peri-implant inflammation or suppuration; (c) absence of increasing mobility, tested with Periotest; and (d) absence of bone loss or radiolucency around the implants. After 12 months of follow-up, all the loaded implants, after 6 weeks of placement, were approved under all the aforementioned criteria. During the analysis of the increasing mobility, tested with Periotest, and grouping these implants according to the site of implantation (mandible or maxilla), it was possible to observe that the implants presented the same increasing mobility.

The incidence of sexually transmitted diseases recently increased in the United States and Europe due to migration, increase in high-risk behavior, and abandonment of safer sex practices at the advent of antiretroviral combination therapy for human immunodeficiency virus infection. This article presents four cases of primary oral and perioral syphilis with differential diagnoses. It is important to bear this reappearing infection in mind to avoid latent infection. Resembling common oral infections, the primary affect disappears spontaneously, and the infection enters the second stage. The patient remains infected, may further spread the disease, and risks severe organ damage from long-standing infection. The antibiotic cure is inexpensive and safe and spares the patient mucous patches and gumma residuals, apart from severe general sequelae such as thoracic aorta aneurysm and neurosyphilis. However, compliance problems jeopardize clinical and serologic follow-up. The growing syphilis incidence prompts the commemoration of Dr Moriz Kaposi and his dispositive 1891 book Pathology and Therapy of the Syphilis. Moriz Kaposi is acknowledged as one of the heads of the Vienna School of Dermatology, a superb clinician, and renowned teacher.

Dental clinicians and other health care providers have long been concerned about a variety of infectious agents that may be transmitted within the dental setting. Many infectious diseases, including human immunodeficiency virus, hepatitis, tuberculosis, and syphilis are important both because of their potential transmissibility and because the first manifestations of the disease may appear in the oral cavity. Oral disease as a consequence of primary syphilis is rare. This article details a patient presenting with a labial nodule as her only clinical manifestation of undiagnosed primary syphilis.

Lichen planus is the most common dermatologic disease with oral manifestations, and oral lichen planus (OLP) is one of the more common mucosal conditions a clinician is likely to encounter in his or her practice. It is an immunologically based, chronic, inflammatory, mucocutaneous disorder of undetermined etiology. While research over the past decade has dramatically improved the overall understanding of the underlying pathogenesis of OLP, specific details of its pathogenesis and a clear understanding of why certain patients are afflicted while others are not, remains elusive. The care and management of patients with OLP continues to challenge even the most experienced clinician, and strongly suspected associations with chronic liver disease and oral squamous cell carcinoma further complicate matters. To provide prudent and competent care, oral health care providers must have a basic understanding of the impact the disease and/or its treatment may have on their patients.

Objective: In this study, the time-related pH changes that occur in cements having different structures were observed. Method and materials: Eight cements consisting of four permanent and four temporary cements were used. The materials were prepared according to manufacturers' instructions. The materials were used in 0.100 ± 0.02-g increments, with the purpose of standardizing the effect of massive differences. The 80 total specimens, including 10 from each cement type, were prepared, and the pH value of the distilled water was measured at 3, 10, 30, 60, and 120 minutes, and then again 24 hours later. Results: Analysis of variance showed the relation between the kind of cement and its pH change during the course of the study was statistically significant. Conclusion: Though temporary cements indicated neutral pH from the beginning of the study, the acidity of the other cements changed with time and took values approximate to neutral pH within 24 hours.

Objective: The purpose of this study was to evaluate the clinical performance and longevity of Tetric Ceram and Syntac Sprint restorations in stress-bearing areas performed in general practice. Method and materials: The light-curing resin composite Tetric Ceram in combination with the bonding material Syntac Sprint were used as restorative materials in three public dental health clinics. All the restorations were done by general practitioners in an ordinary patient pool attending a public health clinic. Before starting, the general practitioners were instructed and trained in performing the restorations according to a standardized clinical procedure, and the evaluations were done according to United States Public Health Service criteria. One hundred forty-eight restorations (27 Class I, 121 Class II) were done in 123 patients. After 2 years, 140 restorations (95%) could be assessed. Color slides and bitewings were taken to supplement the clinical evaluations of color match, marginal discoloration, secondary caries, and marginal adaptation. Wear of the restorations was evaluated according to the Leinfelder method. Results: After 2 years, 7 out of 148 restorations had failed, giving a failure rate of 5% of the tested materials. Five restorations failed due to hypersensitivity, one to secondary caries, and one to fracture. The wear rate was low (mean 37 µm) and did not result in any replacement. Conclusion: This 2-year study showed that clinically satisfactory results could be obtained using resin composite Class I and II restorations in stress-bearing areas done in general practice on an ordinary clientele when the clinical procedure is standardized.