Quintessence International, 03/2007

Objective: To demonstrate the existing difficulties and variability in the application of evidence-based dentistry by comparing the recommendations made by 4 dental experts for the treatment of a fractured tooth. Method and Materials: A case presentation was given to 4 specialists, who were asked to independently develop and explain their personal favorite treatment strategy, based on the best available external evidence and their clinical expertise. The entire case was then reviewed by an expert in evidence-based medicine and discussed with the first author. Results: Each of the 4 experts relied on different articles in justifying their clinical decisions. The minimal overlap in the literature they cited largely explains the different treatment suggestions: While the endodontist preferred a metal post-and-core and a porcelain-fused-to-metal (PFM) crown, both the operative dentist and the prosthodontist opted for a glass-fiber post/fiber-reinforced resin composite post. The perio-prosthodontist recommended a PFM crown with either a direct or indirect post and core. The citation analysis revealed that little high-quality information is available about what would be the best therapy for horizontal fractures of root-canal-treated anterior teeth. Conclusions: This article illustrates that, although it is now common practice in dentistry to base clinical decision making on external evidence from the literature, search strategies and the resulting clinical recommendations still vary greatly. Keywords: dental abutments, evidence-based dentistry, fixed partial denture, post-and-core technique, resin cements, root canal therapy, tooth fractures, tooth-root injuries, treatment outcome, treatment planning

Objective: To perform a retrospective study on the success of immediately loaded short implants (ie, length ¡Ü 10 mm). Method and Materials: From January 1995 to October 2004, 133 short implants were inserted and immediately loaded. Multiple implant systems were used, with a mean follow-up of about 4 years. Only 3 of the 133 implants were lost (ie, a survival rate of 97.7%), and no statistically significant differences were found among the studied variables; no or reduced marginal bone loss was considered as an indicator of the success rate when evaluating the effects of several factors with the use of a general linear model. Results: By using the survival rate, no differences were detected among the studied variables. On the contrary, the analysis of the success rate by means of a general linear model showed that wider (diameter > 3.75 mm) and longer (length = 10 mm) implants were related to a lower delta insertion abutment junction (or marginal bone loss) and thus a better outcome. Conclusion: Immediately loaded short implants had a high survival rate and success rate similar to those reported in previous studies of 2-stage procedures. Immediate loading of short implants can be considered a reliable technique, although a higher marginal bone loss was to be expected when narrow (diameter ¡Ü 3.75 mm) and shorter (length < 10 mm) implants were used. Keywords: alveolar bone resorption, dental implants, general linear model, immediate loading, oral rehabilitation, short implants

Trauma to the maxillary anterior teeth is a frequent occurrence in children and adolescents. Coronal fractures may now be successfully treated by reattachment of the fractured portions with the latest enamel and dentin bonding agents. Root fractures present with more challenging problems. Conservative and proper management of root fractures will greatly help the preservation of the alveolar bone to facilitate subsequent implant placement. This is a case report of such management spanning over many years, from adolescence to adulthood, when the implants were placed for the final esthetic ceramic crowns. Keywords: alveolar bone preservation, ceramic crowns, coronal fracture, implant, reattachment, root fracture

Objectives: To outline aspects that need consideration in the dental office when treating patients with renal disease and to present data on the oral health parameters of patients during the different phases of their renal disease during a 10-year follow-up period. Differences in clinical and salivary study parameters during the course of treatment of the renal disease were expected to occur. Method and Materials: Altogether, 39 patients with chronic renal failure were examined for dental health. Nine patients (mean age 50.8 years) were followed for 10 years through predialysis, dialysis, and posttransplant stages. The patients were examined clinically and radiographically and by analyzing the biochemical constituents of saliva. Patients' perceptions of oral health were recorded using structured questionnaires. Results: No statistically significant differences were observed in the clinical parameters studied during the follow-up period. However, analyses of saliva components after renal transplantation showed significant improvement compared with components found during the predialysis stage. For example, median salivary albumin concentration, which describes the leakage of serum components to saliva, was 399 µg/mL at the predialysis stage, 353 µg/mL at the dialysis stage, and 181 µg/mL at the posttransplant stage. Conclusions: From the oral health point of view, the outcome was better than anticipated. The lower salivary albumin values after kidney transplantation may reflect the improvement of patients' health during the course of the treatment. Keywords: dental health, dialysis, kidney transplant, oral health, predialysis, saliva

Central ossifying fibroma is the most common benign fibro-osseous neoplasm of the jaw. It is not easy to diagnose ossifying fibroma because its clinical, radiographic, and hist-ologic criteria often overlaps with other fibro-osseous lesions. Based on the analysis of 20 cases, this article describes all the manifestations of central ossifying fibroma and some of the differences with the so-called juvenile active ossifying fibroma. Photographs and radio-graphs of 2 cases showing a number of all the clinical and radiographic features of central ossifying fibroma are presented. The surgical procedure of these cases is also illustrated. Keywords: benign fibro-osseous lesion, cemento-ossifying fibroma, central ossifying fibroma

Objective: To evaluate the apical sealing ability of 2 epoxy resin-based root canal sealers used with 2 different warm gutta-percha obturation techniques and cold lateral condensation. Method and Materials: The root canals of 72 freshly extracted single-root incisors were prepared and randomly assigned to 6 experimental groups. Root canal fillings were performed using either cold lateral condensation, warm vertical condensation, or Thermafil obturators with EndoRez or AH Plus as sealer. After root canal filling, the teeth were stored in 5% methylene blue solution for 7 days. Linear dye penetration was measured in bisected specimens by a calibrated investigator using a light microscope. Results: Statistical analysis revealed significantly higher penetration depths in groups where EndoRez was used (P < .05, Tukey test). Regarding the different obturation techniques, the least amount of dye penetration was observed for AH Plus and EndoRez when warm vertical condensation was used. Conclusion: The results of this study indicate that the apical sealing ability of EndoRez is not as effective as that of AH Plus. Thermafil obturators and warm vertical condensation achieved seals with low dye penetration depth. The use of these techniques might decrease the risk of apical leakage. Keywords: apical seal, cold lateral condensation, dye penetration, obturation techniques, resin-based sealer, Thermafil obturation, vertical condensation

Patients with head and neck cancer receive high doses of localized irradiation therapy, which results in destruction of salivary gland secretion ability. Pilocarpine hydrochloride was shown to have some beneficial effect on quality of life of these patients. Most studies concentrated on adult patients with head and neck cancer with no reference to adolescents. This case report demonstrates the long-term beneficial effect of pilocarpine hydrochloride in maintaining sufficient saliva, oral soft tissue integrity, and caries-free status in an adolescent cancer patient who received a total radiation dose of 6,000 cGy. A suggested protocol for management of irradiated adolescent patients with head and neck cancer is offered. Keywords: adolescent, head and neck radiation, pilocarpine hydrochloride, salivary function, salivary glands

This clinical report describes the prosthodontic treatment of a 60-year-old woman to close an edentulous space in the region of the maxillary canine. Single-retainer resin-bonded fixed partial dentures (FPD) have shown satisfactory results in different studies. Recent in vivo studies have shown excellent results for all-ceramic anterior FPDs after 5 years. In the present situation, a cantilevered all-ceramic FPD chosen to replace a missing maxillary canine showed success at the 2.5-year follow-up. Special attention was given to functional and minimal restorative considerations. The use of single-retainer all-ceramic FPDs is discussed. The present case does not represent a routine and well-documented approach for the replacement of a missing maxillary canine. Rather, it is a rarity that was successful because of space availability, present occlusal scheme, and patient cooperation. Implant-supported restorations always should be considered as the first treatment option in such a clinical situation. Keywords: all-ceramic, cantilever, resin-bonded fixed partial denture

Objective: To compare the levels of matrix metalloproteinase-2 and -9 (MMP-2 and MMP-9) and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in patients with gingivitis and periodontitis and in healthy controls. Methods: Levels of MMP-2, MMP-9, and TIMP-1 were determined by ELISA in patients with healthy gingiva (n = 16), gingivitis (n = 18), and periodontitis (n = 25). The subjects with periodontitis were examined before and 1 month after basic periodontal therapy. Results: Slightly higher concentrations of MMP-9 were observed in patients with periodontitis but without statistical significance. MMP-2 was found to be slightly diminished in these patients. The lowest concentrations of MMP inhibitor (TIMP-1) were observed in patients with periodontitis, in whom the concentrations increased after periodontal treatment. Conclusion: The reduction in TIMP-1 concentrations in disease situations suggests a breakdown of the balance between the amount of MMPs and their inhibitor. Keywords: gingivitis, metalloproteinase, periodontitis, tissue inhibitor of matrix metalloproteinase-1

Central giant cell granuloma is a relatively uncommon benign bony lesion of a variably aggressive nature. This paper presents the case of a 7-year-old boy with central giant cell granuloma in the anterior mandible. In children with mixed dentition, a pathologic lesion could be the underlying cause of regular tooth mobility and exfoliation of primary teeth and can easily be overlooked, especially in cases that are not accompanied by an obvious bony expansion. The clinician needs to be aware of possible oral pathology when tooth mobility and displacement are present, and central giant cell granuloma should be considered in the differential diagnosis for children with maligned and mobile teeth. Keywords: central giant cell granuloma, child, differential diagnosis, tooth exfoliation

Objective: To conduct a preliminary investigation of the relationship between patient satisfaction with oral status and the presence of posterior fixed partial dentures (FPD). Method and Materials: A total of 150 women with intact anterior dental segments, randomly drawn from women's schools for adult education, participated (mean age, 33.8 years; SD, 10.4; range, 20 to 63 years). Each woman was assisted in completing a questionnaire on aspects of her oral health beliefs and satisfaction with oral function, and underwent an on-site clinical examination. Subjects were categorized according to general prosthodontic status: those with missing posterior teeth and no FPDs (MN), those with FPDs (PR), and those who were fully dentate (FD). Their responses to the questionnaire were compared. Results: Value placed on oral health did not differ among the groups. Satisfaction with overall oral status, chewing function, and appearance did not differ between MN and PR, although overall satisfaction and appearance were each significantly greater in FD than in MN (P < .001 and P < .05, respectively). Overall satisfaction was negatively correlated with the mean number of missing teeth (P < .01), although perception of chewing ability did not differ among the groups, nor did it differ in relation to the number of posterior occluding pairs of teeth. Conclusions: The hypothesis that individuals with fixed prosthodontic replacements of their missing posterior teeth are more satisfied with their oral status than those without such replacements was not confirmed, while the question of the importance of patient satisfaction as a positive outcome of oral health care is raised. Keywords: fixed partial denture, oral health, patient satisfaction, prosthodontics, tooth loss

The pregnant woman who presents for dental care requires special consideration. This article reviews physiologic changes associated with pregnancy and current considerations for the dental treatment of pregnant dental patients, as well as for pregnant dental professionals. The limitations and safety of commonly used drugs and anesthetics are discussed. Recommendations for prenatal oral counseling are presented. Keywords: dental treatment, drug use, pregnancy, pregnancy gingivitis, prenatal fluoride, risk factors

Finger-sucking habit, or nonnutritive sucking, usually ceases spontaneously in childhood. If the habit is not broken, however, not only will dental occlusion be affected, but the shape of the finger may be altered as well. When the habit is broken, the threatening disturbances of digital growth and dental occlusion will resolve spontaneously. This article describes a unique type of habit-breaking appliance applied on the sucked fingers of 2 children with mental retardation. The advantages of this type of extraoral appliance are discussed. Keywords: acrylic appliance, finger-sucking habit, habit breaker, mentally retarded children

Objective: To compare oral sugar clearance, salivary flow rate, buffer capacity, salivary counts of mutans streptococci and lactobacilli in whole saliva, and root caries in subjects with secondary Sjögren syndrome with those of healthy subjects. Method and Materials: Twenty subjects with secondary Sjögren syndrome and 20 healthy subjects (age 30 to 55 years; all women) rinsed their mouth with a 20% sucrose solution. Before the rinse and 2, 5, 10, and 30 minutes after the rinse, 2 paper disks were soaked with saliva, 1 under the tongue and 1 in the mandibular vestibule. The salivary sucrose concentration was determined enzymatically. The clearance time and the area under the sugar clearance curve (AUC) were calculated. Results: Patients with secondary Sjögren syndrome and with low salivary flow had longer sugar clearance times in the mandibular buccal vestibule and sublingual regions than did healthy individuals (P = .000 and P = .000, respectively). Significant differences of AUC values between the groups for the buccal and sublingual regions were also found (P = .000 and P = .003, respectively). Conclusion: Subjects with secondary Sjögren syndrome had longer sugar clearance time, related to low salivary flow, high counts of cariogenic microorganisms, and decayed and filled surfaces in the root. Keywords: lactobacilli, mutans streptococci, salivary flow, salivary sugar clearance, secondary Sjögren syndrome

Objectives: To compare the cervical microleakage of titanium copings veneered with 3 porcelain-based materials with that of titanium copings veneered with 2 indirect polymeric materials. Method and Materials: Commercially pure, grade 2 titanium was veneered with 3 porcelain systems specially designed for fusing on titanium: Ti22 (Noritake), Triceram (Esprident), and Vitatitankeramik (Vita). Additionally, 2 polymeric materials were used for veneering titanium: Chromasit and Targis (Ivoclar). Four veneer crowns for each titanium-veneer combination were obtained. After storing the specimens in basic fuchsin, the microleakage between titanium and veneer in the cervical area was assessed by measuring the extent of dye penetration within the interface. ANOVA and post hoc statistics were used to analyze the data. Results: Chromasit exhibited the highest mean microleakage score (3 ± 0.816). The least mean microleakage at the interface was recorded for Ti22 porcelain (0 ± 0.0), followed by Triceram (0.25 ± 0.50), Vitatitankeramik (0.75 ± 0.957), and Targis (1.5 ± 1.732). Only the differences between each porcelain system and Chromasit were significant (P < .05). Conclusion: Within the limitations of this in vitro study, there was no significant microleakage between titanium copings and the porcelain veneers, regardless of the porcelain system. The microleakage between titanium and the polymeric materials depended on the veneering material. Leakage was significantly higher when Chromasit was used. Keywords: interface, microleakage, polymeric material, porcelain, titanium

Objective: To compare in vitro the retentive values of stainless steel, parallel-sided posts to quartz-fiber, tapered posts for 2 different dowel lengths (5 and 10 mm). Method and Materials: Both post systems were cemented with a dual-cure adhesive resin cement. Single-rooted extracted human teeth (n = 40) were decoronated and randomly divided into 4 groups of 10 samples each. Posts of 5 and 10 mm in length were luted with the resin cement. Each sample was placed on a universal testing machine, and using a push-out method, a vertical load was applied at a crosshead speed of 2 mm/min. The amount of force required to dislodge the post was recorded. The effect of post type and length was evaluated using a 2-way analysis of variance. Results: A statistically significant main effect was found for post length (P < .001), with the 10-mm posts of both post systems requiring greater force to dislodge than the 5-mm posts. There was no interaction between post length and post type (P > .05). Conclusion: It is concluded from this study that there is no statistical difference in retention between quartz-fiber, tapered posts and stainless steel, parallel-sided posts when they are cemented with the same resin cement (P > .05). The study also concludes that adequate retentive values are achieved with both post systems at the shorter, 5-mm post length. Keywords: post and core, post retention, quartz-fiber post, root canal therapy, stainless steel post

Objective: To evaluate the influence of cavity design and photocuring method on the marginal seal of resin composite restorations. Method and Materials: Seventy-two bovine teeth were divided into 2 groups: group 1 received box-type cavity preparations, and group 2 received plate-type preparations. Each group was divided into 3 subgroups. After etching and bonding, Z250 resin composite (3M Espe) was applied in 2 equal increments and cured with 1 of 3 techniques: (1) conventional curing for 30 seconds at 650 mW/cm2; (2) 2-step photocuring, in which the first step was performed 14 mm from the restoration for 10 seconds at 180 mW/cm2 and the second step was performed in direct contact for 20 seconds at 650 mW/cm2; or (3) progressive curing using Jetlite 4000 (J. Morita) for 8 seconds at 125 mW/cm2 and then 22 seconds at 125 mW/cm2 up to 500 mW/cm2. The specimens were thermocycled for 500 cycles and then submitted to dye penetration with a 50% silver nitrate solution. Microleakage was assessed using a stereomicroscope. Data were analyzed using analysis of variance and Tukey test (5% level of significance). Results: A statistically significant difference was found between groups when a double interaction between photocuring and cavity preparation was considered (P = .029). Conclusions: No one type of cavity preparation or photocuring method prevented micro-leakage. The plate-type preparation showed the worst dye penetration when conventional and progressive photocuring methods were used. The best results were found using the 2-step photocuring with the plate-type preparation. Keywords: cavity preparation, microleakage, photocuring, resin composite

Objective: To observe the effect of 10% carbamide peroxide bleaching agent on the enamel, dentin, and cementum of human teeth. Method and Materials: Teeth were treated with one of two 10% carbamide peroxide bleaching agents (3M Zaris, 3M Espe; Nite White Excel, Discus Dental) for 2 hours/day for 7 or 14 days. Treated teeth and 10 additional nontreated teeth were immersed in 50% silver nitrate solution. The prepared surface was then viewed under a confocal laser scanning microscope, photomicrographs were taken, and the degree of penetration of silver nitrate into the structure of bleached teeth was determined. Results: No penetration was seen in enamel of any group, and statistical analysis showed a significant difference in the degree of penetration only between treated and nontreated groups of dentin and cementum (P < .05). No significant difference was seen between 7 and 14 days. Conclusion: Although the effect was not significant, further investigation is needed to determine the effect of long-term treatment of carbamide peroxide on human tooth substance. Keywords: carbamide peroxide, cementum, dentin, enamel, penetration, silver nitrate