Oral Health and Preventive Dentistry

Purpose: This study aimed to compare insulin status and dysglycemia (prediabetes/diabetes) of patients with chronic (stage III, grade B) or aggressive periodontitis (stage III, grade C) to that of a healthy population. Materials and Methods: Patients with chronic (CP, n = 16) or aggressive periodontitis (AP, n = 15) and periodontally healthy controls (n = 32) were recruited. Body mass index was calculated. Glycemia, plasma insulin, glycated hemoglobin, C-reactive protein, and lipid levels were measured in fasting. The Homeostasis Model Assessment was used to calculate the insulin sensitivity (HOMA-%S), the beta-cell function (HOMA-%B), and their hyperbolic product (HOMA-%BxS). Results: The CP group showed statistically significantly insulin resistance with a lower HOMA-%S (p = 0.0003) and a reduced HOMA-%BxS (p = 0.049) despite a higher insulin level (p = 0.01) vs the control group, even after BMI adjustment. There was also a trend to dysglycemia (prediabetes/diabetes) in the chronic group. In patients with AP, no abnormalities in insulin status were observed and glycemic levels were comparable with controls. Additionally, patients in both AP and CP groups presented significantly higher CRP levels compared to those of the control group (p = 0.02). Conclusion: Patients with CP showed reduced insulin sensitivity, increased insulin levels but a reduced %BxS product and a trend to dysglycemia. These abnormalities were not observed in AP. Keywords: diabetes, periodontal disease, risk factor(s), systemic health/disease

Summary: Periodontal disease (PD) and Alzheimer’s disease (AD) are inflammatory diseases affecting the adult population of the world. PD is mainly caused by infection with Porphyromonas gingivalis (P. gingivalis) and by the synergistic action of various microorganisms. These microorganisms penetrate into the subgingival tissue and cause bacteremia, leading to disruption of the homeostasis of the internal environment of the body. Virulence factors known as gingipains, which are cysteine proteases and other toxins, including fimbria and lipopolysaccharides (LPS), are strongly associated with periodontitis and other systemic inflammation. PD has a known polymicrobial aetiology, and patients who eventually develop sporadic AD tend to have recurrent infections before a clinical diagnosis of dementia. AD, the most common neurodegenerative disease, is characterised by poor memory and specific hallmark proteins. An increasing number of studies have shown that periodontal pathogens are increasingly associated with this form of dementia. Many articles have shown that P. gingivalis infections directly increase the risk of PD and may indirectly lead to the development of AD. However, these links and probable pathogenesis remain to be explored. The aim of this review was to explore whether P. gingivalis periodontal infection is associated with AD and to provide possible mechanisms of association. Keywords: Alzheimer’s disease, neurodegenerative disease, periodontal disease, Porphyromonas gingivalis (P. gingivalis)

Purpose: The present study systematically reviewed randomised controlled trials (RCT) to investigate the efficacy of Er:YAG laser (ERL) as a debridement method in surgical treatment of advanced peri-implantitis. Materials and Methods: An electronic database search and a manual search were performed until March 2022. Outcome measures were clinical attachment level (CAL) gain, probing depth (PD) reduction, plaque index (PI) and bleeding on probing (BOP). The addressed PICO question was: Is ERL an effective debridement tool in the surgical treatment of advanced peri-implantitis? Results: Five eligible randomised clinical trials (RCTs) were included in the qualitative analysis, one of which had unclear risk of bias. One study reported a statistically significant difference in terms of implant CAL gain and PD reduction in favour of the experimental group vs the control group, while four studies did not report any difference between the two groups. Conclusion: Due to methodological heterogeneity, such as non-standard control groups and laser parameters, this systematic review demonstrated inconclusive findings in terms of the efficacy of Er:YAG laser as a debridement method in surgical treatment of advanced peri-implantitis. The results of this review should be considered preliminary and further, well-designed studies with standardised comparators with laser parameters are warranted. Keywords: efficacy, Er:YAG laser, peri-implantitis, systematic review

Purpose: To evaluate the relationship between self-rated oral health, subjective oral conditions, oral health behaviours, and oral health-related quality of life (OHRQoL) in Chinese college students. Materials and Methods: An online cross-sectional survey was conducted, inviting college students from eastern China to participate. A total of 1708 participants were included. A structural equation model was constructed to explain and assess the associations among self-rated oral health, subjective oral conditions, oral health behaviours, and OHRQoL. Results: Self-rated oral health had a direct positive effect on subjective oral conditions and OHRQoL. Oral health behaviours had direct negative impacts on subjective oral conditions and OHRQoL as well as on tooth condition perception and oral health interventions. Subjective oral conditions had a direct positive effect on OHRQoL. There was a positive correlation between oral health behaviours and self-rated oral health. In addition, subjective oral conditions partially mediated both the effect of oral health behaviours on OHRQoL and the effect of self-rated oral health on OHRQoL. Conclusion: There were influential associations between self-rated oral health, subjective oral conditions, oral health behaviours, and OHRQoL among college students in eastern China. Making the most of their association can be a guide to radically improving the oral health of college students. Keywords: oral health behaviours, oral health-related quality of life, self-rated oral health, structural equation modeling, subjective oral conditions

Purpose: To investigate the survival rate of dental implants in patients diagnosed with osteogenesis imperfecta (OI). Materials and Methods: The study is a retrospective analysis of six individuals (2 males, 4 females) with OI (type I, III and IV) with a total of 25 dental implants. Clinical examination included plaque index, gingival index, periodontal pocket depth for each implant, presence of pus, and loosening of the implant(s). Marginal bone loss was measured on radiographs. The observation period ranged from 2–17 years (mean:7.5 years, median: 5 years). Results: The overall implant survival rate was 80%. One patient with OI type III lost five implants. However, four out of five lost implants functioned for 11 years. Conclusion: Dental implant treatment seems to be a valid option for replacing missing teeth in OI patients. It is recommended that patients diagnosed with OI undergo the same preoperative evaluation as regular dental implant patients with special emphasis on a healthy periodontal status and ideal oral hygiene. Keywords: dental implants, implant success, implant survival, osteogenesis imperfecta

Purpose: To investigate the absolute wear caused by toothpastes with highly discrepant REA (Relative Enamel Abrasivity) and RDA (Relative Dentin Abrasivity) values on both enamel and dentin: Candida Peppermint (CP; REA: 1; RDA: 42), Colgate Total Original (CTO; REA: 4; RDA: 100), Signal White System (SWS; REA: 8; RDA: 143), and Candida White Diamond (CWD; REA 244; RDA: 12). Materials and Methods: Eighty (80) bovine enamel samples and 80 dentin samples were divided into four groups each (n = 20) and investigated after a 6-h brushing procedure (21,600 cycles, 60 cycles/min, load of 2.5 N) with the four toothpastes. The abrasive enamel and dentin wear were registered using a contact profilometer. The median and interquartile range (IQR) of the abrasive enamel and dentin wear were calculated for each group. Pairwise comparisons were conducted using the Wilcoxon signed-rank exact test, and the p-value was adjusted according to Holm (statistical significance set at 0.05). Results: CWD led to the highest abrasive enamel wear (9.86 μm [5.77]). CTO caused the highest abrasive dentin wear (166.70 μm [69.90]), being statistically significantly higher than the wear for CP (54.20 μm [24.00]) and CWD (17.00 μm [7.80]) (p = 0.00001). The abrasive dentin wear for CWD was statistically significantly lower in comparison to all other groups (p = 0.00001). Conclusion: Toothpastes with highly discrepant REA and RDA values presented statistically significantly different absolute wear on enamel and dentin. REA and RDA values should both be declared for every toothpaste. Keywords: abrasive dentin wear, abrasive enamel wear, RDA, REA, toothpaste abrasivity

Purpose: Periodontal disease is potentially related to certain kinds of cancer. This review aimed to summarize the relationship between periodontal disease and breast cancer, providing some strategies for the clinical treatment and periodontal health care of breast cancer patients. Materials and Methods: Systematic reviews, randomised controlled trials, prospective and retrospective clinical studies, case series and reports were collected using search terms entered into the PubMed, Google Scholar and JSTOR databases. Results: Research has provided some evidence that periodontal disease is related to the occurrence and development of breast cancer. Periodontal disease and breast cancer have some common pathogenic factors. Periodontal disease may affect the initiation and development of breast cancer involving microorganisms and inflammation. Periodontal health is affected by radiotherapy, chemotherapy, and endocrine therapy for breast cancer. Conclusions: Periodontal therapy for breast cancer patients should be performed differently according to the stage of cancer treatment. Adjuvant endocrine treatment (e.g. bisphosphonates) has a great impact on oral treatment. Periodontal therapy contributes to the primary prevention of breast cancer. Periodontal health care of breast cancer patients is worthy of clinician attention. Keywords: breast cancer, clinical treatment, periodontal disease, periodontal health care

Purpose: Periodontitis is associated with caspase and proinflammatory mediators, such as caspase-1 and tumor necrosis factor-alpha (TNF-α). The aim of this study was to evaluate the salivary levels of caspase-1 and TNF-α and determine their accuracy in differentiating periodontitis patients from individuals with a healthy periodontium. Materials and Methods: This case-control study enrolled 90 subjects, aged 30 to 55, attending the Department of Periodontics at Baghdad’s outpatient clinic. Patients were initially screened to evaluate their eligibility for recruitment. After applying inclusion/exclusion criteria, subjects with a healthy periodontium were included in group 1 (controls), while subjects with periodontitis were included in group 2 (patients). The salivary levels of caspase-1 and TNF-α in participants’ unstimulated saliva were measured using an enzyme-linked immunosorbent assay (ELISA). Then the periodontal status was determined using the following indices: full-mouth plaque, full-mouth bleeding on probing, probing pocket depth, clinical attachment level, and gingival recession. Results: TNF-α and caspase-1 salivary levels were higher in periodontitis patients than in healthy controls and were positively correlated with all clinical parameters. A positive significant correlation between TNF-α and caspase-1 salivary levels was noticed. For differentiating periodontal health and periodontitis, the area under the curve (AUC) values of TNF-α and caspase-1 were 0.978 and 0.998, while the proposed cut-off points were 128.163 pg/ml and 1.626 ng/ml, respectively. Conclusion: The present findings supported a previous discovery that periodontitis patients have significantly higher levels of salivary TNF-α. In addition, there was a positive correlation between the salivary levels of TNF-α and caspase-1. Furthermore, caspase-1 and TNF-α showed high sensitivity and specificity in the diagnosis of periodontitis, as well as distinguishing periodontitis from periodontal health. Keywords: caspase-1, periodontitis, saliva, TNF-α

Purpose: To evaluate the effect of bovine milk and yogurt on selected oral microorganisms and different oral biofilms. Materials and Methods: Milk was prepared from 0.5% fat (low-fat) and 16% fat (high fat) milk powder. For yogurt preparation, the strains Lactobacillus delbrueckii ssp. bulgarcius and Streptococcus thermophilus were added to the milk. Minimal inhibitory concentrations (MIC) and minimal microbiocidal concentrations (MMC) of the test compounds were measured against various microorganisms by the microbroth dilution technique. Cariogenic periodontal biofilms and one containing Candida were created on plastic surfaces coated with test substances. Further, preformed biofilms were exposed to the test substances at a concentration of 100% for 10 min and thereafter 10% for 50 min. Both colony forming units (cfu) and metabolic activity were quantified in the biofilms. Results: Neither high-fat milk, low-fat milk nor casein inhibited the growth of any species. Yogurt and L. delbrueckii ssp. bulgaricus at low MIC and MMC suppressed the growth of Porphyromonas gingivalis and other bacteria associated with periodontal disease. High-fat yogurt decreased cfu in the forming periodontal biofilm by 90%. Both low- and high-fat yogurts reduced metabolic activity in newly forming and preformed periodontal and Candida biofilms, but not in the cariogenic biofilm. Conclusions: Yogurt and L. delbru eckii ssp. bulgaricus, but not milk, were bactericidal against periodontopathogenic bacteria. Yoghurt reduced the metabolic activity of a Candida biofilm and a periodontal biofilm. Yogurt and L. delbrueckii ssp. bulgaricus may have potential in prevention and therapy of periodontal diseases and Candida infections. Keywords: Candida, caries, milk products, oral bacteria, periodontitis

Purpose: Education is well-known as a determinant of oral health and dental behaviours in high-income countries, but much less is known for countries with lower incomes. This study aimed to identify the extent to which education affects oral health and dental behaviours in Indonesia. Materials and Methods: This study used data from the Indonesian Basic Health Survey 2013. From this nationally representative sample of 945,057 people 5–100 years old, a series of mixed-effects Poisson regression models that accounted for sampling weights estimated the effect of educational attainment on edentulism, dental care utilisation, and toothbrushing behaviour. Results: Consistent educational gradients were found for all outcomes and across all model specifications. People without a formal educational degree had a 1.03 (95% CI: 1.03–1.04) times higher risk of not utilising any dental care, a 3.15 (95% CI: 2.47–4.02) times higher risk of being edentulous, and a 15.6 (95% CI: 12.76–19.02) times higher risk of having low toothbrushing frequency than people having a university degree or higher. Conclusions: Stark and consistent educational gradients were observed in the dentate status, dental services utilisation, and toothbrushing in Indonesia. Educational inequalities were much larger for toothbrushing behaviours than for dental care utilisation. Intervention points for health policy should urgently prioritise public health interventions to promote overall educational attainment, preventive services, and dental care targeted at those with lower educational attainment. Keywords: edentulism, educational inequality, dental service utilisation, population-based study, toothbrushing frequency

Purpose: To assess the levels of oral health-related quality of life (OHRQoL) in orthodontic patients both during the suspension of dental services caused by COVID-19 and after a year of dental service reinstatement, and to evaluate the associated factors for OHRQoL in those patients during the suspension period. Materials and Methods: A cross-sectional online study was conducted both during the suspension of dental service due to COVID-19 (T1) and after a year of dental service reinstatement (T2). The questionnaire – consisting of personal information, subjective complaints, OHIP-14 and oral health conditions – was completed by the participants at T1 and T2. Data were evaluated by the Χ2 test, the Wilcoxon rank-sum test, and multivariate logistic regression analysis. Results: 324 participants were ultimately included in the study sample. The participants reported higher OHIP-14 total scores at T1 than T2 (p < 0.001). Statistically significant differences were detected in the domains psychological discomfort, psychological disability, social disability and handicap (p < 0.001). The multivariate logistic regression analysis showed that wearing fixed appliances, being over 18 years old, having delayed orthodontic treatment and poor oral hygiene habits were statistically significantly associated with higher OHIP-14 total scores at T1 (p < 0.05). Conclusion: The OHRQoL in orthodontic patients was negatively impacted by the suspension of dental services during COVID-19, which was reflected in all the psychosocial domains. Types of appliances, ages, delays in follow-up visits and oral hygiene habits seemed to be the factors associated with OHRQoL in orthodontic patients during the suspension. Keywords: COVID-19, oral health, oral hygiene, psychosocial factors, quality of life

Purpose: Antibiotics play an important role in treating periodontal diseases. Due to the effectiveness of antibiotic therapies, their usage in dentistry has significantly increased. The aim of this study focused on the in-vitro susceptibility of different gram-negative oral bacteria species – which are associated with periodontal diseases (Fusobacterium spp., Capnocytophaga spp. and Leptotrichia buccalis) and have different geographical origins (Asia and Europe) – against antimicrobials that are clinically relevant in dental therapy. Materials and Methods: A total of 45 strains were tested (29 Fusobacterium spp., 13 Capnocytophaga spp. and 3 L. buccalis) that were either isolated from Chinese patients or were obtained from different strain collections. Their antimicrobial susceptibility to the antimicrobial agents benzylpenicillin, amoxicillin, amoxicillin-clavulanic acid, ciprofloxacin, moxifloxacin, clindamycin, doxycycline, tetracycline and metronidazole was tested using the E-Test. Strains with particular resistance to penicillin, clindamycin and metronidazole were further analysed for resistance genes. Results: All tested bacterial isolates were sensitive to amoxicillin, amoxicillin-clavulanic acid, doxycycline and tetracycline, but showed variable sensitivity towards other antibiotics such as benzylpenicillin, ciprofloxacin, moxifloxacin, clindamycin and metronidazole. Conclusion: The results of the present study suggest that certain periodontal disease-related bacterial strains can be resistant towards antimicrobial agents commonly used in adjuvant periodontal therapy. Keywords: antibiotics, resistance, oral bacteria, clinical isolates, E-test

Purpose: Since NaOCl acts as a strong oxidizing agent and presents potential toxicity, this study was adressed to evaluate the in-vitro safety of NaOCl solutions at concentrations below the limit of patient tolerance, i.e. ≥ 0.5%. Materials and Methods: First, an in-silico evaluation was conducted to predict the potential toxicity of NaOCl in terms of mutagenic, tumorigenic, irritant, and reproductive risks, as well as some drug-like properties of the molecule. The in-vitro experiments were based on 2D and 3D models. For the 2D approach, two selected cell lines – HaCaT (human skin keratinocytes) and HGF (human gingival fibroblasts) – were exposed to NaOCl at five concentrations (0.05 – 0.5%) for 10, 30, and 60 s to simulate possible clinical administration. The irritative potential of NaOCl 0.05% and 0.25% was assessed in a 3D in-vitro model (EpiDerm, reconstructed human epidermis). Statistical significance was set at p < 0.05. Results: The main findings suggest that NaOCl exerts cytotoxicity towards HaCaT immortalised keratinocytes and HGF primary gingival fibroblasts in a cell type-, dose- and time-dependent manner, with the most prominent effect being recorded in HaCaT cells after 60 s of treatment with NaOCl 0.5%. However, NaOCl was computationally predicted as free of mutagenic, tumorigenic, irritant, and reproductive toxicity, and showed no irritative potential in 3D reconstructed epidermis at concentrations of 0.05% and 0.25%. Conclusion: Further clinical and histological studies are required to confirm these results, as well as elucidate the potential cytotoxic mechanism induced by NaOCl in HaCaT and HGF cells at the tested concentrations. Keywords: periodontitis, primary gingival fibroblasts, sodium hypochlorite, toxicity

Purpose: Saudi children have poor oral health; however, little data are available on the effects of dental caries and its clinical complications on the oral health-related quality of life (OHRQoL) in school-aged children. This study evaluated the impact of caries and its clinical effects on the OHRQoL of a sample of 8- to 10-year-old children attending King Abdulaziz University Hospital. Materials and Methods: The following variables were assessed for each child: sociodemographic data, OHRQoL using an Arabic-validated Child Perception Questionnaire for 8- to 10-year-old children (CPQ8–10), and two global health rating questions. Caries and its clinical effects on oral health were also assessed using the decayed-missing-filled teeth (dmft/DMFT) and pulpal involvement, ulceration, fistula, and abscess (pufa/PUFA) indices. Descriptive statistics of the sociodemographic variables and responses to the CPQ8–10 questions are presented as absolute values and percentages. The CPQ8–10 scores between children with different dmft/DMFT and pufa/PUFA scores were compared. Results: In total, 169 children participated in this study. The means ± SD of dmft and DMFT were 5.03 ± 2.5 and 2.35 ± 1.7, respectively. However, the pufa and PUFA scores were 1.03 ± 1.6 and 0.05 ± 0.2, respectively. The most common oral health complaint affecting OHRQoL was food stuck to the teeth. Participants with higher dmft and pufa/PUFA scores had statistically significantly higher CPQ8–10 scores than did their counterparts. Conclusion: High dmft and pufa/PUFA scores have a statistically signifcantly negative effect on the OHRQoL among healthy 8- to 10-year-old children. Worse global health ratings correlate with lower OHRQoL. Keywords: dental caries, oral health, paediatric dentistry, quality of life, school-age population

Purpose: To determine the self-perceived oral health and general health as well as the oral health-related quality of life (OHRQoL) among parents in Kuwait. Materials and Methods: This cross-sectional study was conducted among parents visiting the School Oral Health Programme (SOHP) clinics in all the governorates in Kuwait. Being a parent and able to read and understand the Arabic language was the inclusion criterion. A convenience sample of parents (n = 2357) were enrolled in this study, which was conducted using a self-administered questionnaire in Arabic. The questionnaire included previously validated questions and also questions designed for this study. The parents completed and returned the questionnaire while waiting for their children in the waiting area of the SOHP clinic. Results: The mean age of the parents was 38.3 ± 7.3 years. The majority (75.2%) of the participants perceived their oral health ‘excellent’, ‘very good’ or ‘good’ and 76.4% also rated their general health as ‘excellent’, ‘very good’ or ‘good’. Overall, higher levels of perceived oral health were reported more frequently by younger participants, females, Kuwaitis, and those who had higher levels of education (p < 0.001). Most of the participants (72.3%) were satisfied with their oral health, (91.0%) enjoyed eating their food and (79.0%) liked their smile. Perceived difficulty in chewing food was stated by only 21.0%, and very few (5.0%) had speech difficulties. Almost half (45.0%) mentioned that they had never had any dental and/or gum problems that affected their daily activities during the past 6 months, nor did such problems influence their social activities. Nearly two-thirds (61.0%) stated that they never had any difficulty in conversation, and half (49.0%) did not report any disturbance in their sleep. Cronbach’s alpha (0.89) showed a high degree of internal consistency between different OHRQoL responses. Conclusion: Most of the parents were satisfied with their oral health, which had an impact on their quality of life. Keywords: general health perceptions, Kuwait, oral health perceptions, parents, quality of life

Purpose: The subgingival area is only reached to a limited extent during home oral hygiene with the aids available to date. The question was investigated whether a newly developed, flattened cross-sectional design of interdental brushes (IDBs) can extend their subgingival reach. Materials and Methods: In part I, the passage-hole diameters (PHD) of IDBs of different sizes and side-bristle lengths, with circular and flattened cross-sections, were compared according to the ISO standard 16409/2016. In part II, handling of flattened IDBs was described based on a case report of a patient with generalised stage 4, grade C periodontitis with locally persistent pockets. Results: Depending on the brush’s size, flattening of IDBs reduced the PHD by 1-18 intervals. IDBs with longer side bristles could thus be inserted into interdental spaces with equal force. This may increase the potential range of IDBs in the vertical dimension. Regular instruction and check-ups are necessary to enable correct handling, as the flattened brushes can only be used in two positions. The observations documented in the case report (duration: 1.5 years) showed that flattened IDBs were associated with reduced signs of inflammation (reduction of pocket depths from 6 to 3 mm, absence of bleeding on probing). Conclusion: IDBs with a flattened cross-sectional design have not been previously described in the literature. It was shown that flattening of IDBs leads to a size-dependent decrease in PHD. Based on a case report, it was hypothesised that the design change of the IDBs could be clinically relevant in the case of persistent deep pockets in narrow interdental spaces. However, this can only be verified or falsified by clinical studies. Keywords: flattened interdental brushes, preventive dentistry, subgingival oral hygiene

Purpose: To analyse whether the stage of apical development affects the effectiveness of regenerative endodontic treatment by comparing the outcomes for necrotic mature and immature permanent teeth treated with regenerative endodontic procedures. Materials and Methods: Multiple databases (PubMed, Cochrane Library, Web of Science, EMBASE and OpenGrey databases) were searched through February 17th, 2022. Inclusion criteria were randomised controlled trials that included treatment of necrotic immature or mature permanent teeth using any regenerative endodontic procedures (REPs) that aimed to achieve pulp revascularisation or regeneration. The Cochrane Risk of Bias 2.0 tool was used to assess risk of bias. The included indicators were asymptomatic sign, success, pulp sensitivity, and discolouration. The extracted data were expressed by percentage for statistical analysis. The random effect model was used to explain the results. Comprehensive Meta-Analysis Version 2 was used to perform the statistical analyses. Results: Twenty-seven RCTs were eligible for inclusion in the meta-analysis. The success rates of necrotic immature and mature permanent teeth were 95.6% (95% CI, 92.4%-97.5%; I2=34.9%) and 95.5% (95%CI, 87.9%-98.4%; I2=0%), respectively. The asymptomatic rates of necrotic immature and mature permanent teeth were 96.2% (95%CI, 93.5%-97.9%; I2=30.1%) and 97.0% (95%CI, 92.6%-98.8%; I2=0%), respectively. The treatment of immature and mature necrotic permanent teeth with REPs yields high success rates and low symptomatic rates. The incidence of positive sensitivity response for electric pulp testing in necrotic immature permanent teeth (25.2% [95% CI, 18.2%-33.8%; I2=0%]) was lower than that in necrotic mature permanent teeth (45.4% [95% CI, 27.2%–64.8%; I2=75.2%]), and this difference was statistically significant. The restoration of pulp sensitivity seems to be more evident in necrotic mature permanent teeth than in necrotic immature permanent teeth. The crown discolouration rate of immature permanent teeth was 62.5% (95% CI, 49.7%-73.8%; I2=76.1%). Necrotic immature permanent teeth have a considerable crown discolouration rate. Conclusion: REPs for both immature and mature necrotic permanent teeth yield high success rates and promote root development. The vitality responses seem to be more evident in necrotic mature permanent teeth than in necrotic immature permanent teeth. Keywords: dental pulp necrosis, meta-analysis, regenerative endodontics

Purpose: This study investigated the effect of toothbrush bristle stiffness and brushing force on the cleaning efficacy in vitro. Materials and Methods: Eighty bovine dentin samples were allocated to eight groups (n=10). Two custom-made toothbrushes of different bristle stiffness (soft and medium) were tested at four different brushing forces (1, 2, 3 and 4 N). Dentin samples were stained in black tea and brushed (60 strokes/min) for a total of 25 min in a brushing machine with an abrasive solution (RDA 67). Photographs were taken after 2 and 25 min of brushing time. Cleaning efficacy was measured planimetrically. Results: After 2 min of brushing, the soft-bristle toothbrush did not cause statistically significantly different cleaning efficacy at different brushing forces, while the medium-bristle toothbrush cleaned statistically significantly less efficaceously only at 1 N. Comparing the two different toothbrushes, higher cleaning efficacy was observed only at 1 N for the soft-bristle brush. At 25 min brushing time, the soft-bristle cleaned statistically significantly better at 4 N compared to 1 N and 2 N and at 3 N compared to 1 N. Using the medium-bristle, cleaning efficacy increased with increasing brushing force. After 25 min of brushing, no statistically significant difference was observed between the two different toothbrushes. Conclusion: Irrespective the brushing force, the use of a soft or medium toothbrush results in comparable cleaning efficacy. At 2 min brushing time, increasing the brushing force does not increase the cleaning efficacy. Keywords: bristle stiffness, brushing force, cleaning efficacy, toothbrush

Purpose: To investigate the prevalence, clinical manifestations and related risk factors of malocclusion in schoolchildren of Jinzhou City, China. Materials and Methods: A total of 2162 children aged 6–12 years were randomly selected from various districts of Jinzhou. Conventional clinical examination was performed by stomatologists, and the results were described based on different clinical manifestations of malocclusion and individual normal occlusion. Further, a questionnaire survey completed by children’s parents or guardians provided the demographic data, lifestyle, and oral habits. The distribution of individual normal occlusion and malocclusion was documented in percentage, and Pearson’s Χ2 was used for two-factor analysis. The data were statistically analysed using SPSS software (version 25.0) with a significance level of α = 0.05. Results: A total of 1129 boys and 1033 girls were included in this study, i.e. 52.2% and 47.8% of the total number of children, respectively. The prevalence of malocclusion in children aged 6–12 years old in Jinzhou was 67.9%, of which crowded dentition was the most common form, with a prevalence of 71.8%, followed by deep overbite, anterior crossbite, dental spacing, deep overjet, anterior edge-to-edge occlusion, and anterior open bite. In the logistic regression model, the results showed that BMI index had little effect on the occurrence of malocclusion (p > 0.05), while dental caries, bad oral habits, retained primary teeth, and a low labial frenum were all related to the occurrence of malocclusion (p < 0.05). Moreover, the higher frequency and duration of bad oral habits were associated with a higher likelihood of malocclusion. Conclusions: The prevalence of malocclusion in children aged 6–12 years in Jinzhou is high. In addition, bad oral habits (such as lip biting, tongue thrusting, biting/gnawing objects, unilateral chin supporting, and unilateral mastication) and other related risk factors (such as dental caries, mouth breathing, retention of primary teeth, and low labial frenum, etc) were associated with malocclusion. Keywords: children, epidemiological investigation, malocclusion, risk factors

Purpose: To assess the root surface roughness and substance loss induced by chemical and chemomechanical challenges on root surfaces pretreated with ultrasonic instrumentation, a hand scaler, or erythritol airflow. Materials and Methods: One hundred twenty (120) bovine dentin specimens were used in this study. Specimens were divided into eight groups and treated as follows: groups 1 and 2: polished with 2000- and 4000-grit carborundum papers but not instrumented (‘untreated’); groups 3 and 4: hand scaler; groups 5 and 6: ultrasonic instrumentation; groups 7 and 8: erythritol airflow. Samples from groups 1, 3, 5, and 7 then underwent a chemical challenge (5 x 2 min HCl [pH 2.7]), whereas samples from groups 2, 4, 6, and 8 were subjected to a chemomechanical challenge (5 x 2 min HCl [pH 2.7] + 2 min brushing). Surface roughness and substance loss were measured profilometrically. Results: The least substance loss through chemomechanical challenge was noted after erythritol airflow treatment (4.65 ± 0.93 µm), followed by ultrasonic instrumentation (7.30 ± 1.42 µm) and the hand scaler (8.30 ± 1.38 µm); the last two (hand scaler and ultrasonic tip) did not differ statistically significantly. The highest roughness after chemomechanical challenge was observed on ultrasonically treated specimens (1.25 ± 0.85 µm), followed by hand-scaled specimens (0.24 ± 0.16 µm) and those subject to erythritol airflow (0.18 ± 0.09 µm); there was no statistically signficant difference between the latter two, but they both differed statistically significantly from the ultrasonically treated specimens. No statistically significant difference in substance loss through the chemical challenge was observed between specimens pretreated by the hand scaler (0.75 ± 0.15 µm), ultrasonic tip (0.65 ± 0.15 µm), and erythritol airflow (0.75 ± 0.15 µm). The chemical challenge smoothed the surfaces treated with the hand scaler, ultrasonic tip, and erythritol airflow. Conclusion: Dentin pretreatment with erythritol powder airflow resulted in a higher resistance to chemomechanical challenge than did dentin treated ultrasonically or with the hand scaler. Keywords: erythritol airflow, hand scaler, ultrasonic, substance loss, surface roughness

Purpose: This study aimed to clarify the impact of the coronavirus disease 2019 (COVID-19) pandemic on individual dental-visit behaviour and examine the difference between elderly and other individuals regarding the impact on dental visits. Materials and Methods: An interrupted time-series analysis was performed to examine the change in data from the national database before and after the first declaration of a state of emergency. Results: The number of patients visiting a dental clinic (NPVDC), number of dental treatment days (NDTD) and dental expenses (DE) during the first declaration of a state of emergency decreased by 22.1%, 17.9%, and 12.5% in the group under 64 years of age and 26.1%, 26.3%, and 20.1% in the group over 65 years of age, respectively, compared with those in the same month of the previous year. Between March and June 2020, the monthly NPVDC and NDTD were significantly reduced (p < 0.001, p = 0.013) in those over 65 years of age. The DE did not change statistically significantly in either the under 64 group or the over 65 group. There was no statistically significant change in the slope of the regression line in the NPVDC, NDTD, and DE before and after the first state-of-emergency declaration. Conclusion: The first state of emergency greatly reduced the NPVDC, NDTD, and DE compared to those in the previous year. In people aged over 65 years, it might still be unresolved 2 years after the postponement of dental treatment owing to the first declaration of a state of emergency. Keywords: clinic visits, elderly, interrupted time-series analysis, stay at home orders, universal health insurance

Purpose: Pregnancy is a state particularly sensitive to oral pathologies (periodontal and decay). The oral health status of pregnant women can have an impact on the outcome of the pregnancy and the oral health of the child to come. As in the general population, the oral health of pregnant women is socially determined and dependent on psychosocial factors, including factors related to health behaviours. Research into the determinants of oral health in pregnant women will allow a better understanding of the mechanisms of action specific to this period of perinatality. Materials and Methods: The methodology of a scoping review was selected with the objective of investigating the contribution of knowledge, attitudes, practices (KAP) and oral health literacy on pregnant women’s oral health. Results: Of the 67 articles selected, 52 studied the ‘knowledge’ component, 27 the ‘attitude’ (including the perception and beliefs concerning health), and 54 the ‘practice’ component, while 6 articles examined literacy. The KAP components were studied in relation to socioeconomic determinants, oral health status, healthcare utilisation and oral health literacy. The level of oral health literacy of pregnant women is strongly related to their living environment and socioprofessional level which influences their attitudes and practices. Woman’s oral health practices before pregnancy can be a predictor of her practices during pregnancy. Conclusion: The complex nature of the attitude component (locus of control, sense of self-efficacy, perceived importance) is little discussed. The heterogeneity and exhaustiveness of topics related to KAP raises the question of how to more accurately assess KAP in pregnant women in a valid, reproducible, and transferable manner and the need to build a structured oral health consensus body of work. This review is a first step towards identifying the psychosocial factors that are essential for developing a model of educational intervention in oral health that combines the process of behavioural change and decision making while taking into account the concept of empowerment, and with the aim of reducing social inequalities in health. Keywords: health literacy, knowledge-attitude-pratice, oral health, pregnant women and child, scoping review

Purpose: To synthesise and characterise nanosilver sodium fluoride (NSSF) and assess the effect of applying this formulation in vitro on artificially demineralised root dentin lesions, compared with the application of silver diamine fluoride (SDF), sodium fluoride (NAF) or no treatment, in terms of mechanical, chemical and ultrastructural properties. Materials and Methods: NSSF was prepared using 0.5 wt% chitosan solution. On 40 extracted human molars, the buccal aspect of the cervical thirds of roots were prepared and divided into 4 groups of 10 each: control (no treatment), NSSF, SDF and NaF (n = 10). The specimens were examined using scanning electron microscopy (SEM), atomic force microscopy (AFM), and x-ray photoelectron spectroscopy (XPS). Fourier transform infrared spectroscopy (FTIR), surface and cross-sectional microhardness and nano-indentation tests were performed to determine the mineral and carbonate content, microhardness, and nanohardness, respectively. Statistical analysis was performed to determine the differences between the different treatment groups for the set parameters using parametric and non-parametric tests. Tukey’s and Dunnet’s T3 post-hoc tests were further used for multiple comparisons between groups (α = 0.05). Results: The control group (no treatment) was found to have statistically significantly lower mean scores for surface and cross-sectional microhardness compared with all other test groups (NaF, NSSF and SDF) (p < 0.05). Spearman’s rank correlation test showed statistically insignificant differences between the mineral-to-matrix ratio (M:M) and carbonate content of all groups (p < 0.05). Conclusions: Treatment of root lesions with NSSF yielded comparable results to SDF and NaF under in-vitro conditions. Keywords: caries, demineralisation, fluoride, nanoparticles, root dentin, silver

Purpose: To research the role of microRNA (miR)-152 in the pathogenesis of pulpitis using a cell model based on human dental pulp cells (HDPCs) treated with lipopolysaccharides (LPS). Materials and Methods: The biological activity of HDPCs infected by LPS was measured using a cell counting kit (CCK-8), Transwell test, flow cytometry, and fluorescent quantitative PCR. The concentration of superoxide dismutase (SOD) and malondialdehyde (MDA) was evaluated using an assay kit, the levels of interleukin (IL)-1β and IL-6 were measured by enzyme-linked immunosorbent assay (ELISA), and the targeting relationship between SMAD5 and miR-152 was measured by the double-luciferase report test. The expression of cell cycle-related CyclinD1 and BAX was assessed by PCR. By plotting a receiver operating characteristic (ROC) curve, the diagnostic value of miR-152 was shown. Results: The level of miR-152 in HDPCs induced by LPS decreased, while the level of SMAD5 increased. After overexpressing miR-152 in LPS-induced HDPCs, the viability was elevated, the apoptosis rate decreased, CyclinD1 was elevated, BAX diminished, the inflammatory cytokines (IL-6 and IL-1β) were inhibited, the activity of SOD increased, and the MDA content decreased. miR-152 targeted regulation of SMAD5, and SMAD5 modulated the effects of miR-152 on cell viability, apoptosis, inflammation, and the oxidative response of HDPCs. Reduced miR-152 expression was verified in patients with pulpitis, which could be a biomarker for pulpitis. Conclusion: miR-152 was found to be a biomarker correlated with the pathogenesis of pulpitis and the biological behaviour of HDPCs. Keywords: diagnostic value, human dental pulp cells, miR-152, pulpitis, SMAD

Purpose: The present study assessed the efficacy of 0.12% chlorhexidine (CHX) and Salvadora persica-based mouthwashes (SPM) in reducing oral Candida carriage (OCC) and periodontal inflammation in cigarette smokers and non-smokers after non-surgical periodontal treatment (NSPT). Materials and Methods: Self-reported cigarette smokers and non-smokers with periodontal inflammation as well as non-smokers with a healthy periodontal status were included. NSPT was performed in all participants. Based on the type of mouthwash, participants were randomly divided into three groups as follows: group 1: CHX; group 2: SPM; and group 3: distilled water (ddH2O) with mint flavour (control group). Clinical attachment loss (CAL), plaque index (PI), gingival index (GI), probing depth (PD), and marginal bone loss (MBL) were measured. Clinical periodontal parameters were re-assessed at a 6-week follow-up. Oral yeast samples were collected and identified using a concentrated oral-rinse culture technique and PCR, respectively. Clinical and laboratory-based investigations were done at baseline and after six weeks. Statistical significance was set at p < 0.05. Results: At baseline, PI, MBL, PD and CAL were comparable in all participants. None of the patients had periodontitis at baseline. Post-operatively, CHX and SPM were more effective in reducing PI (p < 0.01), GI (p < 0.01) and PD (p < 0.01) in non-smokers than in the control group. The OCC was statistically significantly higher among smokers compared with non-smokers at baseline. At the 6-month follow-up, CHX was more effective than SPM in reducing OCC in non-smokers (p < 0.01). At the 6-week follow-up, there was no difference in OCC among cigarette smokers regardless of the type of mouthwash prescribed postoperatively. Conclusion: In cigarette smokers and non-smokers, CHX and SPM are effective in reducing periodontal soft-tissue inflammation after NSPT. Post-operative use of CHX is more effective than SPM in reducing OCC. Keywords: chlorhexidine, mouthwash, non-surgical periodontal treatment, periodontal inflammation, Salvadora persica, smoking

Purpose: This review aimed to highlight the aetiology and risk factors of food impaction along with the treatment in each case. Materials and Methods: A search was conducted in PubMed from 1947 to March 28, 2023. The search terms utilised included (food impaction) OR (interdental impaction). No filter was applied. Articles related to the classification, aetiology, treatment, and associated factors of food impaction in dentistry and published in English or with an abstract in English were selected. Results: A total of 72 articles were included in the review, which revealed the variety and complexity of aetiological factors and treatment of food impaction in dentistry, as well as the heterogeneity of previous studies. Based on the aetiology, different treatment plans and management should be considered. Conclusion: This review indicated the need to identify the pathology of food impaction before treatment. Considering the causal factors of food impaction – including proximal contact loss, occlusal disharmony, morphological deformity, positional abnormality, and interdental papillae loss – different management approaches such as restoration, occlusal adjustment, orthodontic, nonsurgical or surgical treatment could be applied. Further clinical and experimental research is warranted to address the prevention and treatment of food impaction in dentistry. Keywords: food impaction, periodontitis, proximal space, proximal contact, restoration

Purpose: This study aimed to compare the cell toxicity and biological characteristics of Ketac GIC (glass-ionomer cement), Nexus RMGIC (resin-modified glass-ionomer cement), and RelyX RC (resin cement) in human periodontal stem cells (PDSCs). Materials and Methods: To compare the effects of Ketac GIC, Nexus RMGIC, and RelyX RC on PDSCs, the cements were diluted from 1:2 to 1:8. PDSCs were then treated with the serially diluted cements with or without N-acetyl-cysteine (NAC), and cell survival was measured using water-soluble tetrazolium salt (WST-1) assay. Intracellular reactive oxygen species (ROS) was measured using 2′,7′-dichlorofluorescin diacetate (DCFDA), and western blot analysis was performed to observe phosphorylation and activation of extracellular signal-regulated kinase (ERK) by Nexus RMGIC or RelyX RC. Results: Cell death and proliferation were dose-dependently reduced following Nexus RMGIC or RelyX RC treatment. In addition, Nexus RMGIC or RelyX RC showed an increase intracellular ROS generation compared to Ketac GIC. Pretreatment with NAC confirmed the suppression of cell toxicity and ROS generation induced by Nexus RMGIC or RelyX RC. Nexus RMGIC or RelyX RC activates ERK phosphorylation, not p38 phosphorylation, in PDSCs. Conclusion: This study showed that the treatment with Nexus RMGIC or RelyX generates intracellular ROS and cell death through the ERK signaling pathway in PDSCs. In contrast, these effects were not observed with Ketac GIC, indicating that resin-based materials may have cytotoxic and genotoxic effects on PDSCs. Keywords: cytotoxicity, ERK, human periodontal stem cells, resin monomer, ROS

Purpose: To evaluate the effect of a mouthwash containing Lespedeza cuneata extract (LCE) on halitosis as an alternative to chemical mouthwashes. The effect of this natural mouthwash on halitosis-causing bacteria (HCB) was clinically evaluated. Materials and Methods: A total of 84 subjects among 103 participants were recruited from the M Dental Clinic (Busan, South Korea) in this randomised, double-blind, placebo-controlled study. The participants were divided into two groups: 41 in the saline-gargle group (saline group) and 43 in the LCE-gargle group (LCE group). A week before the experiment, scaling and oral health education were conducted to standardise the subjects’ oral condition. For clinical evaluation, halitosis and HCB were evaluated pre-gargle (baseline), immediately after gargling (treatment), and 5 days after gargling (5 days post-treatment). Statistical analysis was performed using SPSS for Windows. Results: The level of subjective improvement was statistically significantly greater in the LCE group than the saline group (p < 0.05). Compared with the saline group, the LCE group showed reduced halitosis after 5 days of application. Furthermore, halitosis statistically significantly decreased over time (p < 0.05). Moreover, the LCE group showed a statistically significant decrease in the number of all six HCBs (p < 0.05). Conclusion: LCE gargle was effective in reducing halitosis both subjectively and objectively, suggesting an antibacterial effect on HCBs in the oral cavity. Thus, LCE, which can be used as a safe mouthwash ingredient, can promote oral health and will be valuable for the oral healthcare product industry. It might also be helpful for people suffering from halitosis. Keywords: bacteria, halitosis, Lespedeza cuneata, mouthwash, natural extracts

Purpose: To evaluate the inhibitory effects of Streptococcus salivarius K12 and M18 strains on the growth of six oral pathogens as well as their release of volatile sulfur compounds (VSCs), and whether these probiotics can inhibit the expression of arginine-specific gingipain A (RgpA), a protease secreted by Porphyromonas gingivalis. Materials and Methods: After six halitogenic oral pathogens (P. gingivalis, Treponema denticola, Tannerella forsythia, Fusobacterium nucleatum, Parvimonas micra, and Eikenella corrodens) were cultured with or without S. salivarius K12 and M18, the concentration of two VSCs was measured. Moreover, the antimicrobial activity of S. salivarius K12 and M18 against these pathogens and the suppressive effect on RgpA release by P. gingivalis were assessed. Results: In the co-culture of S. salivarius K12 or M18 with oral pathogenic bacteria, the growth of all six oral pathogens was significantly inhibited (p < 0.01). Additionally, S. salivarius K12 and M18 had an inhibitory effect on the production of the halitogenic substances H2S and CH3SH (p < 0.01) as well as the expression of P. gingivalis RgpA. Finally, we demonstrated that the addition of only culture supernatants of the two strains K12/M18 to oral pathogen cultures was sufficient to mimic the effects of K12/M18 co-cultures upon VSCs production and protease expression. Conclusions:S. salivarius K12 and M18 inhibited VSC release by all six of the major oral pathogens that were assayed and reduced the expression of RgpA. Keywords: gingipain, oral malodour, probiotics, Streptococcus salivarius K12, Streptococcus salivarius M18

Purpose: During the Coronavirus Disease 2019 (COVID-19) pandemic, there has been concern about nosocomial infections acquired through dental practice, where machines – such as air turbines – that generate aerosols are used, and where there are many opportunities to come into contact with saliva and blood. Because there is no report to date on whether dental treatment is associated with a risk of SARS-CoV-2 infection in Japan, the aim of the present cross-sectional study was to examine the risk of SARS-CoV-2 infection associated with dental treatment. Materials and Methods: Cross-sectional data were gathered from the Japan COVID-19 and Society Internet Survey (JACSIS), a large-scale internet survey conducted in 2021 (n=28,175). From September 27, 2021, to October 30, 2021, the questionnaires were distributed to candidates selected from the panelists of a Japanese Internet research company to represent the Japanese population regarding age, sex, and residential prefecture using a simple random sampling procedure. The risk of SARS-CoV-2 infection related to dental treatment was examined and analysed. Results: Multivariable logistic regression analysis showed that younger age, male sex and living alone were statistically significant factors positively associated with SARS-CoV-2 infection, whereas the presence or absence of dental treatment was not statistically significantly correlated with SARS-CoV-2 infection. Conclusion: The present epidemiological study showed that dental treatment is not a positive risk factor for SARS-CoV-2 infection in Japan. Keywords: COVID-19, health concerns, infection control, oral medicine, special needs

Purpose: The adjunctive subgingival application of sodium hypochlorite/amino acid and a mixture of natural and cross-linked hyaluronic acid gels (high molecular weight) has been recently proposed as a novel modality to enhance the outcomes of non-surgical periodontal therapy. The aim of this prospective case series was to evaluate the clinical outcomes obtained following the subgingival application of a combination of sodium hypochlorite/amino acid and a mixture of natural and cross-linked hyaluronic acid (high molecular) gels in conjunction with non-surgical periodontal therapy. Material and Methods: Twenty-one systemically healthy, non-smoking patients diagnosed with stage II-III, grade A/B periodontitis underwent full-mouth subgingival debridement (SD) performed with ultrasonic and hand instruments. All sites with probing depths (PD) ≥ 4 mm were treated with additional repeated (i.e., 2-3 times) instillation of sodium hypochlorite/amino acid gel in the periodontal pockets prior to and during SRP. Following mechanical debridement, a mixture of natural and cross-linked hyaluronic acid (high molecular) gel was applied in the pockets. The primary outcome variable was PD reduction; changes in clinical attachment level (CAL) and bleeding on probing (BOP) were the secondary outcomes. The clinical parameters were assessed at baseline, 3 and 6 months after therapy. Results: Compared to baseline, a statistically significant mean reduction of PD values was obtained after 3 and 6 months, amounting to 2.6 ± 0.4 mm, and 2.9 ± 0.4 mm, respectively (p < 0.001). Mean CAL gain measured 2.3 ± 0.5 mm at 3 months and 2.6 ± 0.5 mm at 6 months in comparison to baseline (p < 0.001). Mean reduction of BOP values was 54.9 ± 16.9 % at 3 months and 65.6 ± 16.4 % at 6 months (p < 0.001). The number of moderate pockets (4-5 mm) decreased from 1808 at baseline to 274 at the 6-month evaluation, and the number of deep (≥ 6 mm) pockets dropped from 319 to 3, respectively. Conclusion: The combination of sodium hypochlorite/amino acid and a mixture of natural and cross-linked hyaluronic acid (high molecular) adjunctive to subgingival debridement may represent a valuable approach to improve the outcomes of non-surgical periodontal treatment. Keywords: cross-linked hyaluronic acid, non-surgical periodontal therapy, periodontitis, sodium hypochlorite/amino acid.

Purpose: The present study aimed to observe the anatomical distribution of gingival melanin pigmentation and evaluate its intensity and extent in different age groups and in correlation with skin and tooth shades. Materials and Methods: The participants of this study were 391 patients attending the Dental University Hospital. The presence of gingival pigmentation was assessed using De Krom’s Oral Pigmentation Chart and its intensity was assessed using the Dummett-Gupta Oral Pigmentation Index. Skin colour and tooth shade were measured using the Fitzpatrick scale and the VITA classical shade guide, respectively. Statistical analyses included descriptive statistics and Pearson’s Χ2 test for the association between the study variables. Results: The prevalence of gingival pigmentation among the sample size was 74.4%, and pigmentations were present on both arches in 57.6% (n = 224) of the participants. The extent (category 1) was highest when pigmentation was evident in both arches, with category 4 being the least extent. Age and sex did not show a correlation with gingival pigmentation. Gingival pigmentation intensity was mild when pigments were present in one arch (p < 0.00), whereas it was heavy when both arches presented with gingival pigmentation. Medium brown colour and tooth shade A1 were the most common among participants with gingival pigmentation (p < 0.00). The association between gingival pigmentation intensity and extent in relation to skin colour was statistically significant (p < 0.00), as was tooth shade (p < 0.05). Conclusions: Gingival pigmentation is highly prevalent in the Saudi population, with different severity and extent levels. The effect of gingival pigmentation on smile and overall facial aesthetics should be considered when providing dental and cosmetic treatments. Keywords: gingival pigmentation, hyperpigmentation, prevalence, skin colour, tooth shade

Purpose: The goal of this study was to assess the peri-implant condition, peri-implant bone loss (PBL), and complication rates of short dental implant-supported splinted crowns (SDI-SCs) and non-splinted crowns (SDI-NSCs) in the maxillary premolar-molar region. Materials and Methods: Patients who had short implants placed near their maxillary sinuses were evaluated. Both patient satisfaction and presence of any technical complication, e.g. porcelain wear and chipping, loss of retention and loosening of the abutment, fixture or screw, were noted. The peri-implant plaque index (PIPI), probing depth (PIPD), bleeding on probing (PIBP), and peri-implant bone loss (PBL) were evaluated. To assess the impact of prosthesis type and SDI placement on technical problems, a log-rank test was computed. p < 0.05 was considered statistically significant. Results: A total of 72 patients agreed to be followed-up, showing a mean follow-up time of 3.1 years. Ninty-five implants in total (55 SDI-SCs, and 40 SDI-NSCs) with moderately rough surfaces were evaluated. The average PBL score for implant and patients was 1.27 (0.02–3.97) and 1.25 (0.03–4.41), respectively. More technical complications were observed with single crowns than with splinted crowns. There were no statistically significant differences in the peri-implant parameters between SDI-SCs and SDI-NSCs (p > 0.05). PBL at molar sites was substantially higher than at premolar sites (p = 0.048). Sixty patients (83.3%) were satisfied with the appearance of the crowns, while 57 patients (79.1%) were satisfied with the crowns’ performance. Conclusion: The peri-implant conditions, bone levels, technical complication rates and patient satisfaction were comparable between the SDI-SCs and SDI-NSCs. However, implants placed in the molar sites had statistically significantly greater bone loss in comparison to those at the premolar sites. Keywords: patient satisfaction, single crowns, short implants, splinted crowns

Purpose: Diets rich in nitrates have the potential to prevent oral diseases such as caries or periodontitis. The reduced forms nitrite and nitric oxide have an antibacterial effect against cariogenic bacteria. The effect on bacterial acid production in saliva and oral biofilm is yet unknown. This study investigated the influence of consuming naturally nitrate-rich beetroot juice on bacterial lactate production in saliva and on the pH value of saliva and oral biofilm. Materials and Methods: In addition to their usual diet, a study group of eight subjects consumed 50 ml of beetroot juice daily for a fortnight. After a two-week break, they rinsed with 0.2% chlorhexidine (CHX) for 14 days as a positive control. Bacterial lactate production was induced by rinsing with 50 ml apple juice and measured at different time points during the study. Results: After two weeks of daily beetroot-juice consumption, an accumulation of nitrate and nitrite was measured in the saliva. No influence on the bacterial lactate production in saliva or the saliva and plaque pH was found. Conclusion: Commercially available beetroot juice showed no modulating effects on intraoral bacterial acid production, suggesting no caries-preventive properties under the tested conditions. Keywords: beetroot, caries, nitrate, nitrite

Purpose: To compare the effectiveness of ayurvedic, homeopathic and conventional dentifrices on plaque and saliva in terms of cariogenic bacteria, salivary pH, and plaque pH. Materials and Methods: This double-blinded, parallel-group, randomised controlled trial was performed at Saveetha Dental College and Hospitals, Chennai, India. The participants comprised healthy adults possessing more than 20 permanent natural teeth and having a Decayed Missing and Filled Teeth (DMFT) score, plaque index score, and gingival index score less than or equal to 2. There were 3 intervention groups: 1: herbal dentifrice (Dabur Meswak); 2: homeopathic dentifrice (Gum Forte gel); 3: fluoride dentifrice (Colgate Total). The outcome measures were as follows: plaque and saliva samples were evaluated for pH; colony counts of Streptococcus mutans and Lactobacillus at baseline, 14 and 28 days of follow-up. One-way and repeated measures ANOVA, Wilcoxon signed-rank and Kruskal Wallis tests were used to compare the mean differences of plaque and salivary pH and plaque and salivary S. mutans and Lactobacillus counts at baseline, 14 and 28 days. Results: The mean S. mutans and Lactobacillus counts in plaque and saliva decreased statistically significantly in all treatment groups at the 28-day follow-up. Mean plaque pH was not statistically significantly different at the 14-day follow-up (p-value = 0.16). On the 28th day, group 1 (7.64 ± 0.20) showed the highest increase in plaque pH followed by group 2 (7.39 ± 0.25) and group 3 (7.27 ± 0.19), which was found to be statistically significant. No statistically significant difference in mean salivary pH was observed between the three groups at the different time points. Conclusion: This study reveals that the herbal dentifrice tested here was effective in reducing cariogenic bacterial count and increasing the plaque pH, thereby warranting the usage of the same. Keywords: biofilm, dental decay, dental plaque, saliva, toothpastes

Purpose: The purpose of the present observational study was to assess the prevalence of radiographic alveolar bone loss (ABL) as a function of age at the Periodontics Clinics at the College of Dentistry, King Saud University, Riyadh, Saudi Arabia. Materials and Methods: Medical and dental healthcare records of individuals visiting the Periodontics Clinics at College of Dentistry, King Saud University, Riyadh Saudi Arabia were assessed. The following information was retrieved: age, gender, educational status, and systemic diseases (diabetes mellitus [DM], hypertension, osteoporosis and obesity). Digital full-mouth radiographs were retrieved from patients’ dental records, and marginal bone loss (MBL) was assessed on the mesial and distal surfaces of all teeth. Logistic regression analyses (LRA) were done to assess the correlation between ABL and gender, age, educational status and duration since diagnosis of the aforementioned systemic conditions. p < 0.05 was considered statistically significant. Results: In total, medical and periodontal healthcare records of 495 individuals were retrieved and assessed. All individuals were citizens of the KSA. Among these, 107 were healthy controls and 98, 95, 96 and 99 individuals had a medical diagnosis of type-2 DM, hypertension, obesity and osteoporosis, respectively. There was no statistically significant difference in the mean age and gender of all medically compromised participants. The prevalence of mild, moderate, and severe periodontitis in the total patient population was 51.4%, 37.5% and 36.5%, respectively. Among all healthy controls, the prevalence of mild, moderate, and severe periodontitis was 16.3%, 25.5% and 33.4%, respectively. There was no difference in the prevalence of mild, moderate, and severe periodontitis in relation to advancing age in the entire patient population. Conclusion: Advancing age did not seem to affect ABL in the present patient population. Patient education, oral hygiene maintenance and SES seem to be more predictable indicators of ABL than increasing age. Keywords: alveolar bone loss, diabetes mellitus, hypertension, obesity, osteoporosis, prevalence

Purpose: The aim of this in-vitro study was to investigate the antimicrobial efficacy of identical experimental toothpastes with different stannous sources. Materials and Methods:Streptococcus mutans biofilms were grown on protein-coated glass disks in static conditions for 24 h and thereafter exposed to toothpaste slurries or physiological saline (negative control; n = 15) for 30 s. Four experimental toothpastes were applied in this study, containing either stannous chloride (SnCl2; B: 3500 ppm Sn2+, and D: 3600 ppm Sn2+) or stannous fluoride (SnF2; C: 3500 ppm Sn2+, and E: 3600 ppm Sn2+). Marketed toothpaste meridol® (A: 3300 ppm SnF2) served as control. All five toothpastes contained amine fluoride (AmF). The biofilms were placed on agar surface and their metabolic activity was assessed by isothermal microcalorimetry over 96 h. The heat flow data was analysed for growth rate and lag time using grofit package in software R. Additionally, reduction of active biofilm compared to untreated control was calculated. Results: All toothpastes significantly prolong the lag time of treated biofilms in comparison to negative control (p < 0.05). Toothpastes containing SnF2 (C and E) prolonged the lag time statistically significantly compared to toothpastes containing SnCl2 (B and D) (p < 0.05). The maximum growth rate was statistically significantly reduced by all tested toothpastes compared to the untreated control group (p < 0.05). Toothpastes containing SnF2 (A, C and E) reached 59.9 ± 7.8, 61.9 ± 7.7, and 55.6 ± 7.0% reduction of active biofilm, respectively. Thus, they exhibit statistically significantly better results than toothpastes B (52.9 ± 9.9%) and D (44.7 ± 7.6%). Toothpaste D, which contains a slightly higher concentration of Sn2+, was the least effective in reducing active biofilm. Conclusion: The toothpastes containing SnF2 combined with AmF had the highest antimicrobial efficacy in this study. Keywords: antimicrobial, biofilm, caries, stannous chloride, stannous fluoride, toothpaste

Purpose: The growing demand for implants has led to their implementation by general dental practitioners (GDPs) in clinical practice. The present study assessed referral patterns of GDPs for the surgical phase of implant dental treatment. Materials and Methods: One hundred fifty GDPs were asked to fill out a structured questionnaire containing their demographic data and answer six questions characterising their referral patterns for implant dentistry. Results: Forty-one (41%) percent performed the surgical phase, and 87% provided implant restoration. Gender was the only influencing factor for the surgical phase, as 51.4% of male GDPs and 6.5% of female GDPs performed implant surgery themselves. Experience and practice set-up did not influence the referring decision. Fifty-four percent of the practitioners referred 0 to 5 patients per month, and the chosen specialists were: 80% oral and maxillofacial surgeon, 11% periodontist, and 9% selected a specialist depending on the individual case. The major reasons influencing the referral pattern were the complexity of the surgical procedure, followed by systemic medical compromise of the patient. Conclusions: Most implant surgeries in Israel are still performed by specialists. Keywords: dental implant, implant placement, referral patterns

Purpose: While the objective of partial pulpotomy is to preserve the vitality and function of the pulp tissue, the preopera-tive pulp status is the main prognostic factor for its success. To date, however, there is little data on long-term success rates. Therefore, the aim of this prospective pilot study was to assess the long-term outcome of partial pulpotomy in per-manent teeth after carious pulp exposure without signs or symptoms of irreversible pulpitis, verified clinically, radio-graphically, and via MMP-9 levels. Materials and Methods: Patients in whom permanent teeth with extremely deep carious lesions were diagnosed as com-pletely asymptomatic (n = 8) or with signs of reversible pulpitis (n = 10) underwent non-selective caries removal followed by a blood test to assess the level of MMP-9. The teeth were thereafter partially pulpotomised, MTA-capped, and immedi-ately restored with composite resin. Follow-up examinations were performed by endodontically experienced examiners focusing on clinical and radiographic assessment. Results: One patient could not be contacted and was lost to follow-up. Overall, the follow-up period ranged from 2–8 years (mean = 4.4 years). The majority of teeth remained functional and without pathology; one tooth was classified as having failed because of a vertical root fracture. There was no statistically significant difference in the groups’ success rate (p = 0.3). The estimated overall survival rate was 94.1% (95% CI: 0.84-1.00) after 4 years according to the Kaplan-Meier method. Conclusion: Pulp vitality in permanent teeth can be preserved with high success rates by means of partial pulpotomy after carious pulp exposure in asymptomatic teeth or in teeth with reversible pulpitis. Keywords: carious pulp exposure, mineral trioxide aggregate, MMP-9, outcome, partial pulpotomy, vital pulp therapy

Purpose: To investigate the association between plasma antibody levels against Porphyromonas gingivalis (PG) and atrial fibrillation (AF) history in community-dwelling older individuals in Japan. Materials and Methods: This study was a subset of the Uonuma cohort study, including 3091 participants aged 60–79 years. Data were collected, including AF history as a dependent variable, plasma immunoglobulin G antibody levels against PG as an independent variable, and previously reported AF risk factors and demographic information as covariates. Results: The median age of the participants was 69 years. Of the 3091 participants, 1411 (45.6%) were men, and 56 (1.8%) had an AF history. AF prevalence was significantly higher in participants with higher antibody levels against PG than in those with lower antibody levels (3.0% vs 1.4%; p = 0.005). Multivariable logistic regression analysis showed that participants with higher antibody levels against PG had twofold higher odds of having AF (odds ratio = 2.13; 95% confidence interval = 1.23–3.69). Restricted cubic spline analysis indicated a nonlinear relationship between antibody levels against PG and AF history. Conclusion: Plasma antibody levels against PG were associated with AF history in community-dwelling older individuals in Japan. Keywords: antibody level, atrial fibrilation, older adults, periodontitis, Porphyromonas gingivalis, older adults

Purpose: To evaluate the use of concomitant medication in combination with a mouthwash of delmopinol HCl 0.2% based on data from 8 phase III efficacy studies on the mouthwash. Materials and Methods: Clinical data obtained from 8 previously performed phase III studies, carried out to document the clinical efficacy of a mouthwash of delmopinol HCl 0.2% with respect plaque and gingivitis, were used to analyse the use of concomitant medication. In these 8 randomised double-blind clinical phase III studies the patients were – in addition to their normal oral hygiene measures – treated for 2–6 months with mouthwashes containing delmopinol HCl 0.2%, delmopinol HCl 0.1%, chlorhexidine digluconate 0.2% or placebo. The number of visits in each study was three. Each time the patients visited the dentist for efficacy determinations, other data were also recorded. One of these was whether the patient had used any other medication during the study. In this paper, the number of treatments of different types of concomitant medication (antibiotics, nasal decongestants and others) was used as a basis for statistical comparisons between the different test groups. Results: For antibiotics (all indications), a 27% lower number of treatments was obtained in the delmopinol 0.2% group in comparison with the placebo group, and a 41% decrease was observed for treatments with antibiotics for respiratory infections. For nasal decongestants, the number of treatments was 53% lower in the delmopinol 0.2% group. Conclusions: The delmopinol HCl 0.2% solution in patients with gingivitis provided a statistically significant reduction of concomitant use of antibiotics and nasal decongestants. Keywords: antibiotics, Decapinol, decongestants, delmopinol, reduction

Purpose: With success rates comparable to that of root canal treatment, vital pulp therapy (VPT) has gained clinical interest and has been used in the management of young permanent teeth with inflamed pulps. The aim of the present study was to retrospectively evaluate the radiographic success of VPT in young first permanent molars 24 months post-treatment and correlate findings with tooth and treatment-related characteristics. Materials and Methods: Dental records of all patients with first permanent molars which received VPT in the Department of Paediatric Dentistry (National and Kapodistrian University of Athens) were retrieved. Demographic characteristics and data regarding the treatment performed were recorded. Patients’ radiographs were evaluated at 6, 12 and 24 months post-treatment by two qualified paediatric dentists blinded regarding the treatment performed. Radiographic success, reasons for failure and continuation of root development were evaluated. Differences were tested using the Χ2 and Student’s t-test, and possible correlations were determined by calculating the odds ratio. Results: Overall radiographic success rate at 24 months was 77%, ranging between 50% for direct pulp capping and 92% for full pulpotomy. Differences were not statistically significant. Continuation of root development was recorded in almost 1/3 of the teeth and completion in almost 1/5. No statistically significant association was recorded between the outcome and any tooth and treatment-related variables. Conclusion: VPT seems to be a reliable option in the long term for the treatment of deep carious lesions in young permanent molars. Keywords: vital pulp therapy, pulp capping, pulpotomy, radiographic success, root development

Purpose: Healthcare professionals (HCPs) play a key role in improving the health literacy of patients. Since oral health is an essential part of overall health, the objective of this study was to assess the knowledge and attitudes about oral health among registered nurses. Materials and Methods: A four-component questionnaire was used to assess the oral health training, oral health knowledge and attitudes of registered nurses. Participants were recruited from the city of Montpellier, France, and the surrounding area between May and June 2022 via e-mail and social media. Results: In total, 416 responses were included in our study. Only 35.8% of nurses reported that they had received specific training on oral health and 24.3% had never advised patients to consult a dentist. Participants demonstrated good overall knowledge, but stated there were weaknesses in a variety of areas, such as oral health in children. The nurses proposed methods to improve understanding of the importance of oral health, namely by setting up training courses and better interdisciplinary collaboration. Conclusion: Our study showed that some aspects of oral health are not well understood by nurses. Initial training should be improved and supplemental training should be offered to improve the knowledge, attitude and practices of nurses in order to improve patient care. Keywords: attitude, knowledge, literacy, nurses, oral health prevention, training

Purpose: To explore a weighted composite of endodontic inflammatory disease (EID) as a risk factor for suffering a first myocardial infarction (MI). Materials and Methods: Seven tooth-specific conditions related to EID were assessed radiographically in 797 patients suffering a first MI and 796 controls. A weighted composite of EID was calculated as the sum of all teeth, excluding third molars. Using maximum likelihood estimation, each condition was assigned a specific weight. With multivariable conditional regression, EID variables, periodontal disease, and missing teeth were assessed as predictors of a first MI. Results: Periodontal disease (OR 1.38; 95% CI 1.13–1.69, p = 0.0016) and missing teeth (OR 1.03; 95% CI 1.002–1.05, p = 0.034) were related to the risk of a first MI, while none of the EID-related conditions individually were. However, when assessed as an aggregate, a weighted composite of EID (OR 1.97; 95% CI 1.23–3.17, p = 0.0050) and periodontal disease (OR 1.34; 95% CI 1.09–1.63, p = 0.0046) was associated with the risk of MI. Missing teeth did not remain a statistically significant predictor of MI in the final model. Conclusions: A weighted composite of EID was associated with the risk of MI and strengthens the evidence for a direct connection between oral inflammatory diseases and cardiovascular disorders. Keywords: cardiovascular disease(s), endodontics, inflammation, periodontal disease(s), risk factors(s), systemic health/disease

Purpose: The purpose of the present study was to evaluate the level of knowledge of prenatal health professionals concerning the relationship between periodontal diseases and pregnancy complications, as well as their professional implications in the oral health field. Materials and Methods: A questionnaire was distributed to obstetricians/gynecologists, interns specialised in obstetrics/gynecology, midwives, and student midwives at Loire Atlantique and Vendée hospitals (France). The questionnaire included 5 sociodemographic questions and 14 questions regarding the level of knowledge about the relationship between periodontal diseases and pregnancy complications as well as the professionals’ level of involvement in oral health care. Results: Twenty-three obstetricians/gynecologists and 55 midwives responded to the questionnaire. Preterm delivery and chorioamnionitis were the most frequently mentioned complications of pregnancy, whereas the risk of pre-eclampsia was rarely mentioned. Half of the professionals said they were aware of the oral manifestations of pregnancy. Gingivitis and an increased risk of caries were the most frequently mentioned items, whereas epulis was the least frequently mentioned item. The level of involvement of prenatal care practitioners in oral health care was limited due to a lack of competence and time. Nevertheless, 64% of the participants discussed the risks of poor oral hygiene with their patients. Conclusion: There is good knowledge among French gynecologists/obstetricians and midwives regarding the oral manifestations of pregnancy. However, there is still a lack of knowledge concerning the links between periodontal diseases and pregnancy complications. The involvement and behaviour of pregnancy professionals in the oral health field is inadequate. The present survey highlights the need to improve the initial and continuing education of obstetricians and midwives on this topic. Keywords: attitude, health knowledge, midwife, obstetrician/gynecologist, practice, periodontal disease, pregnancy

Purpose: To investigate the effect of the supplementation of energy drinks with green tea extract on abrasive and erosive dentin wear. Materials and Methods: Six groups, each comprising 15 bovine dentin samples, were prepared, yielding a total of 90 samples. Erosion was performed by immersing the samples in Red Bull and Red Bull light with and without green tea extract. Tap water with and without green tea extract was used as the control groups. The samples were subjected to abrasive/erosive cycling for five days. The following cycling was performed daily: toothbrush abrasion (20 brushstrokes; 2.5 N); eight erosive cycles (2 min storage in the respective solutions); in between the erosive cycles, storage in artificial saliva (60 min) and again toothbrush abrasion (20 brushstrokes; 2.5 N). During the night, samples were again stored in artificial saliva. Abrasive/erosive dentin wear was measured using a stylus profilometer (µm, accuracy = 40 nm). The measured dentin loss results from the vertical position shift on the y-axis from base to final profile after the wear process in 2D. Pairwise comparisons between the groups were carried out using Wilcoxon signed-rank test. Results: The following dentin wear (median [IQR]) was measured: Red Bull: 1.9 µm (0.5); Red Bull Light: 1.3 µm (0.3); Red Bull with green tea extract: 0.8 µm (0.3); Red Bull Light with green tea extract: 0.3 µm (0.5); Tap water with green tea extract: -0.2 µm (0.7); Tap water: -1.0 µm (1.2). The comparison of all tested groups to each other proved to be statistically significant (p < 0.05). Conclusion: The supplementation of energy drinks with green tea extract provide a protective effect against erosive/abrasive wear in vitro. Keywords: abrasive dentin wear, energy drinks, erosive dentin wear, green tea, profilometry

Purpose: To compare the long-term effects of the Ministry of Public Health’s (MOPH) caries preventive interventions for 6- to 12-year-olds (supervised toothbrushing [STB], dental sealant, and combined STB+sealant) to the base case (no intervention) using the System Dynamics Model. Materials and Methods: The System Dynamics Model was used to evaluate the intervention scenarios of supervised toothbrushing (STB), sealant, and combined STB+sealant with the base-case scenario. The effectiveness data for the model’s interventions were obtained from systematic reviews and meta-analyses. Results: The model determined that the caries-free population increased by 36.2%, 25.5%, and 14.5%, while the caries-affected population decreased by 8.1%, 5.5%, and 3.1% in the combined STB+sealant, sealant, and supervised toothbrushing scenarios compared to the base case at 15 years of age. Conclusion: Combined STB+sealant is the most efficacious intervention among those administered to children between the ages of 6 and 12 with permanent teeth. In addition, the System Dynamics Model could be helpful in comparing interventions or policies to determine the optimal intervention for a given population. Keywords: dental caries, preventive intervention, system dynamics model